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Many of you may have heard
that The Centers for Medicare and Medicaid Services and Office of the National Coordinator for Health Information Technology held a “listening session” in Washington on May 3, 2013. The meeting was with stakeholders to discuss EHRs and billing. Hmmm…I bet many of you weren’t invited.
You may also have heard that The American Health Information Management Association is urging more research on the causes of higher levels of coding and reimbursement through the use of electronic health record. Sue Bowman, Senior Director of coding policy and compliance, hasreiterated their view, “The extent to which EHRs have led to improper reimbursement is unclear. EHRs produce more complete and accurate documentation and this could be leading medical providers to seek reimbursement for services they have always been providing, but weren’t properly documenting before. Higher levels of reimbursement do not necessarily equate to fraud.” [Good for AHIMA to share this very important tidbit the government bean counters must have overlooked when they estimated disbursements from their mandated EHRs!]
I’ve written several articles on coding the past year, emphasizing the issues that will and are resulting from too complicated a coding system. Here's one you might like to check out. IDC-10 Codes, There's Got to Be a BETTER Way!
This latest round about coding is a perfect example of the documentation mess we're in, except in the reverse. Now physicians are getting accused of seeking higher reimbursements because their EHRs are allowing them to more accurately document all the services they are providing - which are legally billable, by the way! Look at this from the physician’s side: They have expensive EHRs they've been mandated to implement. Now they have a capability to document and bill for all their services that they probably missed billing in the past due to “user/billing errors.” Doesn't it make sense that they would bill for all the services they provided - thus helping them pay for their EHRs, employee training, lost productivity, etc? Wow, if you’re healthcare provider in today’s healthcare world, you’re placed in a position of being “damned if you do and damned if you don’t.”
This reminds of our of complicated tax system. For those of us lucky enough to hire a good CPA, we can deduct everything coming to us, but those who can’t afford such professional services, you’re left to filing your taxes with only “street” knowledge that you’ve gathered over the years. And oh yeah, what you’ve learned may or may not be applicable to the newest tax rules, so you’re increasing your chances of being audited by the IRS.
Now back to Ms. Bowman... She’s recommending the development of a code of ethics for EHR vendors and users to design and use the system appropriately, guidelines to ensure features in an EHR are correctly used, development by CMS of a national set of coding guidelines for hospital reporting of emergency department and clinic visits, and education and training on coding with EHRs.
Forgive me, but on the vendor’s side, shouldn’t this be part of the licensing process for EHR software? There will always be some unscrupulous people in all professions, but is it necessary to make more laws to make sure docs are coding correctly? Remember, the new codes haveincreased from 13,000 to 55,000! Getting all the coding done correctly will be like finding a specific shell on the beach. There's a good chance you'll find the wrong shell? Coding accuracy will be a myth!
I would welcome dialog on the issue. It’s a big one for me and I’m hoping it gets you riled up a bit to!
When I turned 18, my parents did what all my friends’ parents did: they cut us loose to start paying for our own stuff. Even those of us who went to college were supposed to kick in and help carry the load – we got jobs on weekends and in the summer to help out with expenses.
I paid my first health insurance bill for myself before my 20th summer. The bill from Blue Cross and Blue Shield was for $59.60 a month. My parents had always been self-employed and paid our family health insurance premium every month, “just like our mortgage. It wasn’t anything we even thought about, it wasn’t optional. You have to have health insurance,” my mom said.
Having grown up with that kind of thinking, I paid my own health insurance every month.
Later On:
When I had kids, health maintenance organizations (HMO) became popular and I could take all my babies for their doctor visits for $5, shots included. I lost some of the choice of providers I had back with Blue Cross and Blue Shield, but the HMO was good, solid coverage. When a baby had to go to the hospital, it was covered. When a child needed surgery, it was covered. And those trips to the emergency room for stitches from falls, they were covered, too. We had comprehensive coverage from a strong corporation that gave my husband good union benefits. We had great suburban providers near our home.
Insurance companies charged us, or our employers, what they needed to charge us to cover the cost of care, including whatever shots and drugs we needed, and to make enough to cover administrative overhead. The money they spend on care for their members is called the Medical Loss Ratio (MLR); from an insurer’s perspective, when you have to pay out, it is a loss.
Typically, insurance companies paid about 80% to 85% of their premiums in MLR and the rest to administration. Health insurance companies charged rates based on the profile of the customer, so when I was young and healthy, my rates were low. When we had a family, rates went up. And as we are getting older, our premiums are rising. It makes sense; those things are determined by actuaries who do underwriting and determine the likelihood that you will draw on your insurance for care.
Back in the day, employers paid benefits to attract and keep good workers, and the coverage was good. Private sector coverage was distinguished from public sector coverage such as government-subsidized Medicaid plans. Medicaid was available to people who were seriously ill and indigent, and you had to meet very strict income and asset limits to qualify.
Where We Are Going:
Today, with all health insurance coming under federal regulations, the distinctions are blurred between private and public coverage. Under the provisions of the new health reform law that fully kicks in next year, health insurers are required to take all comers, and charge premiums for mandated packages. Actuarial tables be damned, Scarlett! Insurers must cover mandated populations with mandated packages and deliver mandated services in ways that are friendly to the population. Premiums will be subsidized with public funds based on income according to a sliding scale. And by the way, remember that MLR where insurers’ liabilities determine what percentage goes for overhead and administration? That percentage is mandated now, too.
When insurance is mandated for everyone, when packages are written according to law and not according to what is logical according to age and utilization, when the amount you can spend for administrative expenses is mandated, the basis for the whole concept of insurance is undermined. It’s like defying the laws of gravity.
When health insurance is written while ignoring the logic of actuarial tables and underwriting principles, it isn’t really insurance anymore. The government is just mandating that a private, third party pay for healthcare for its citizens, and premiums will be subsidized by the government for those who can’t pay. The third party becomes an extension of carrying out the government rules for who is covered, what they get, and even whether they get it.
Yes, those of us who have been watching managed care since the mid-90s have certainly seen that insurance companies have been “rationing” care under depth and breadth of coverage in contracts with employers and private individuals all along. However, it is a rationing system that the purchasers have agreed to within those private contracts. If I get denied coverage, the insurance company can point to the plan that I bought (i.e., the private contract which I entered into with them) and show me that benefit wasn’t included in the coverage I purchased from them.
Within that private contract framework, the insurance companies had discretion regarding the customers with whom they entered into contracts. Some health insurance companies chose to deal in the private insurance market and contract mostly with large employers. Others became specialists in government-subsidized programs like Medicare or Medicaid. They built their premium pricing structure and contracts around their selected markets and the amount of risk they chose to assume with certain populations.
Now What?
Under health reform, insurance companies are regulated so they have to write packages according to federal regulations, offer insurance to mandated groups, and charge rates that under normal underwriting rules defy the laws of simple arithmetic. Some interest groups would have us believe that insurance companies are evil entities that should not be in the business of healthcare; that they are profiting from premiums and denying care because they are the third party standing between the patient and the provider.
In reality, they have assumed the lion’s share of the responsibility in case you have a catastrophic illness, and they also cover preventive care like vaccines because, if for no other reason than simple good business sense for them, it is cheaper to prevent a disease than to treat it. Based on that logic, most health insurance companies are concerned about keeping their members healthy. And when they are mandated to cover certain populations and conditions, they are going to be even more concerned about keeping those populations healthy.
When I was paying $59.60 a month for Blue Cross and Blue Shield, it was wholly voluntary on my part and theirs. I chose them as an insurer and they agreed to write coverage for me. I went to the doctor when I was sick and they held up their end of the deal and paid 80% of my bills. I’m not sure what the business model is going to look like when that contractual arrangement is no longer voluntary by either the patients or the insurance company. I suspect it will get expensive for both parties, as the covered populations will not be chosen by the insurance company as part of their business strategy, and the members will be getting a mandated package of services that they will be required to pay for.
It doesn’t sound exactly like a government-run healthcare system, but then again it doesn’t not sound like a government-run healthcare system, either. And it makes me wonder, armchair health economist* that I am, at what point we just cut out the middle man and eliminate the charade.
*For the record, even though I am a self-declared armchair health economist, I have had the privilege to watch this from a professional perch for awhile. In one particular meeting in the late 90s, academics and government think-tankers gathered to figure out how to rewrite the tax laws to encourage coverage within the free market system. If you are looking for a mental image, think Upton Sinclair’s The Jungle.
Be sure to read Peggy's post this week. In her post,Cost, Compliance and Safety: Are They Mutually Exclusive?, Peggy compares the aviation industry and the healthcare industry, and wonders if we might be heading down the path towards over-regulation in healthcare.
In aviation, safety has always been the primary concern. In
fact, aviation’s safety record is so stellar that it is considered a model for
healthcare. That is quite a testament.
However, a retired pilot friend recently bemoaned that FAA
rules and regulations have overtaken concern about safety, and he postulates
that aviation is not better for the change.
“Now we’re only concerned about compliance…we have a cast of
thousands as support staff. When I started flying in 1964, Part 91 federal
regulations were about 30 pages. You could memorize it. Today, it is hundreds,
if not thousands, of pages and nobody can possibly know everything that is in
there. We are less safe today than we were 50 years ago,” he complained.
Making and keeping track of all those regulations costs
aviation a lot of money. It requires a boatload of federal regulators to
oversee them, and costs private carriers a bundle of money to hire people to
monitor every jot and tittle of the laws. And, he concludes, the passengers and
the airline employees do not benefit from this over-regulation.
Will Healthcare Follow Aviation Again?
Just about everyone in healthcare knows about the vaunted
aviation checklist, and how it has become standard procedure in many operating
rooms today. Books are written and consultants make good livings just teaching
the checklist method of philosophy. The checklist is a great tool. Healthcare
is better for following aviation down that path.
But is healthcare going to benefit by following the FAA down
the road to over-regulation? We can trip on our path toward safety by using
regulations as stumbling blocks instead of paving a smooth road to improved
quality and performance.
One Example From a Pharmaceutical Client
Just last week, I was observing a training class that I
wrote for a major pharmaceutical company. We were training hourly line
employees on procedures that affect product safety. To a person, they had one
complaint: standard operating procedures (SOPs) were becoming downright cumbersome. That makes it very difficult to follow, let alone implement them.
One veteran employee said when an incident occurs, someone writes
another procedure to address that specific event and adds it to the book of
procedures. With each new addition, nothing else in the book is deleted or
changed, and so it is becoming nearly impossible to follow. In fact, the
employee complained that SOPs are written in response to each incident,
meaning that many new SOPs only relate to one isolated event. The SOPs are
losing their meaning and rationale. It is just a jumble of unrelated knee-jerk
reactions to individual events.
The employee concluded that this practice was creating more
problems than it was solving by having a procedure manual that could not be
followed. There are now so many rules to follow, she said, the rules can no
longer be followed.
Is All of Healthcare Headed Toward Unwieldy SOPs?
With the passage of the Accountable Care Act, known
colloquially as ObamaCare, many believe that we are headed down a path of
over-regulation. Where common sense and good medical practice once dominated
the industry, healthcare practitioners (once called nurses and doctors) are
overwhelmed with rules regarding how they practice, to which the actual art and
science of medicine is taking a backseat.
At a recent visit accompanying a friend to a physician’s
appointment at a hospital center, we observed that we were two of only four
people sitting in a new waiting room with 25 chairs. There were two large
semi-circular reception desks – one with four and another with 12
stations – in this cavernous waiting room. Most of the stations were empty. While
we were waiting, a physician accompanied by a nurse and two receptionists
carried a brochure rack around the waiting area deciding where to place it. Let
me say that again. A highly-skilled physician specialist carried around a
brochure rack with his nurse and two receptionists trying to find a place for
it...for about 15 minutes.
In this brand-spanking-new facility where our doctor’s
office had been moved since our last visit (from a very modern, extremely
functional office building now sitting vacant in the parking lot), we also
observed not one, but two printers behind the smaller receptionist desk flanked
by a wall of paper files. We filled out our medical information on a clipboard,
which we have done for each of his visits for the last three years.
The Trend Is…
By personal experience as well as professional observation,
the trend is toward more regulation, more staff to track our compliance with
the rules, and an ongoing steady stream of paperwork to track our patients. Are
cost, compliance and safety mutually exclusive? They don’t have to be and
ideally shouldn’t be. But with the trend toward over-regulation, we may be
missing an opportunity to streamline and cost-cut while serving patients
better.
Instead of continuing to ramp up our regulatory oversight
into the stratosphere, perhaps it is time to – if I can paraphrase my retired
pilot friend – throttle back and re-evaluate what we are really trying to
accomplish.
How would you like your organization to be among the top 10 Places to Work? Well, Fortune Magazine surveyed 259 firms and more than 277,000 employees to find out how they would rate their organization for management credibility, job satisfaction, camaraderie, pay and benefits, hiring practices, communication, recognition, and diversity, but only one healthcare company ended up in their top 10.
The 10 most common answers were no surprise to any of us who follow transparent leadership methodologies, but my favorite “extra” was learning that one CEO posts his/her personal development plan for all employees to see and track results.
This Leader ROCKS! (in my humble opinion...)
While the survey was aimed at all types of corporations, not necessarily healthcare, CHG Healthcare Services ranked third on the list of Best Companies to Work For. Wouldn’t it be great if several hospitals, especially those that have or are currently implementing Lean Healthcare, would be ranked in the top 10 for 2013?
The facts are overwhelming that the most important asset we have is our employees and that all organizations should strive to hire the best candidates they can find to fill needed gaps. One process that is effective for building a best-in-class workforce is consciously hiring people who have skills and knowledge otherwise lacking in the organization - that of course includes hiring for IT and leadership expertise, as well. By doing so, you build a solid company where everyone appreciates and learns from their peers and leaders. It also fosters employee satifaction and patient satisfaction while grooming high potentials for leadership positions.
So healthcare leader, are you brave enough to post your personal development plan for all your employees and peers to see:
What you don’t know now but are trying to learn?
How they are being led by someone who might not be as knowledgeable as they presumed?
What you feel is important for you to become a better leader?
And, oh yeah…
That you’re not perfect, all knowing, etc.?
Trust me, most leaders would be scared to death to let their employees and peers reach into their secret little minds and learn the real truth about them. But folks, we need to step up to the plate and begin modeling transparent leadership so the people around us will feel free to do the same.
Once we all become transparent, we can begin the natural progression of everyone helping each other grow and our organizations and people will benefit socially, personally, professionally and financially. Can’t beat that!
Promoting Transparency beyond our walls:
None of us wants the negative publicity of being linked to lack of transparency. How is your organization rated for pricing transparency? Patients want and deserve to know what they will be charged for procedures. As patients are becoming more informed, they are choosing to be treated at hospitals that willingly publish their fees. For healthcare organizations to be considered best in class, they need to swallow this poison pill and advertise their pricing.
You might want to read this article about Arizona state getting an “F” because price of services are hidden from the public: Arizona gets failing grade for healthcare transparency . I have to believe that healthcare professionals in Arizona work hard to provide excellent patient care; but even so, their hospitals now have a definite black spot on their reputations.
Drum Roll Please: Who will be the first person to step up and comment below:
“Yes, I will post my personal development goals for my peers and employees to see. I will begin the process of encouraging transparency within my healthcare organization.”
“Yes, we will change our pricing policies and post the cost of our services for easy access.”
HEALTHCARE is globalizing, and Workers’ Compensation should be a part of that. There. I’ve said it, and I will explain why. When I attended the 5th World Medical Tourism & Global Healthcare Congress, last week at the Westin Diplomat Resort & Spa in Hollywood, Florida, sponsored by the Medical Tourism Association (MTA), I found just how big this growing industry is getting, and how many countries are getting on the bandwagon to provide lower cost healthcare at the same or better quality than U.S. hospitals are offering, with doctors trained in the U.S. or in other Western countries; the latest technology and medical equipment, and accreditation from the Joint Commission International (JCI), the International Organization for Standardization (ISO), as well as the U.S. Centers for Medicare and Medicaid Services (CMS).
In the paper, I discussed what medical tourism is, how it is being implemented into health care plans, the cost savings of medical tourism, as well as the issue of quality, which is equal to or better in many of these hospitals than most American hospitals provide. I then discussed the state of workers’ compensation medical costs, and finally, the legal barriers medical tourism faces, as well as the legal barriers to implementing medical tourism into medical provider networks for workers’ compensation, using three legal cases pertaining to medical tourism and workers’ compensation claims.
The first one, was in California, and was a case of domestic medical tourism. A cook at a convalescent hospital slipped and fell and injured his right elbow and back. Due to his weight, the treating physician, and his employer’s physicians recommended he lose weight, but since they did not tell him which weight loss clinic to go to, the claimant chose to go to a clinic three thousand miles from his home. The case wound up in the CA Supreme Court, which ruled in his favor, granting him temporary disability for the ten months he was at the Duke University clinic, and for all future costs of medical treatment.
The second case was also in California, and concerned a Mexican worker who fell off of a ladder. He was treated by the State Compensation Insurance Fund and a provider in his hometown of Tijuana. The medical reports were prepared by both the treating physician and another doctor. The Workers’ Compensation Appeals Board made an award to the claimant, the State Fund petitioned for reconsideration, on the grounds that both physicians were not licensed under California law. The Court of Appeals ruled in the claimant’s favor in this case as well.
The last case happened in Florida, and also involved a Mexican worker who was injured when a vehicle struck him as he was unloading trash in the right leg. He was hospitalized for a long period of time and had twelve surgeries to repair the fracture. He was seen by an orthopedist in Dallas, who recommended additional surgery. He never got the surgery in the US, as he returned to Mexico and did not have legal documents to return to the US. This case went to the Florida Court of Appeal which ruled that state law did not preclude the foreign physician’s treatment of the claimant in Mexico. They stated that Florida workers’ compensation law contemplates coverage for non-citizens, and they cited an earlier case in which the court held that undocumented workers were entitled to workers’ compensation coverage in Florida, and two later cases that held that “to construe the section 440.13(2)(a) in a manner that would limit authorized treatment for a claimant injured in Florida to a physician licensed in the State, or anywhere else in the US, would preclude workers (including illegal aliens) who return to their home country from receiving authorized remedial care for clearly compensable injuries.”
The Court of Appeal also stated that Florida law indicates that an injured worker is not prohibited from moving from his pre-injury residence in the state, and receiving treatment outside of the state. As the claimant was no longer living in Florida, the court held that this case was different from three other cases that the defendants cited, in that the claimant was already living in Mexico when he requested medical treatment. Therefore, the trial court did not err in directing the employer/carrier to authorize treatment by a Mexican physician, and the trial court’s decision was affirmed by the court.
These cases are by far not the last ones that will arise in regard to medical tourism and workers’ compensation, and with a growing working class population in the U.S. that is foreign born, there will most certainly be others in the future. And as such, getting these workers treated in their home countries where issues of language, culture, cuisine, family and friends supporting them are not a problem, it will become necessary for employers, workers’ compensation carriers, unions, and the claimant’s themselves to have the same options for treatment that they may be getting from their employer’s health care plan.
What is the difference if a knee or hip replacement is performed on a patient who is injured on the job, or crossing the street and gets hit by a car? There is none, so why should workers’ compensation be any different than health care plans already being implemented, or are being planned for in the future as the medical tourism industry grows, and more businesses arise to facilitate such tourism and more hospitals get in on the game around the world.
Among the nations represented at the Congress were many countries in Central and Latin America such as Mexico, Guatemala, Costa Rica, Nicaragua, Panama, Colombia, Chile, Brazil and Argentina as well as Caribbean countries such as the Bahamas, Barbados and Puerto Rico. Other nations represented there were Poland, Lithuania, Turkey, Thailand, Malaysia and Japan. With many workers comp cases involving both legal and undocumented workers from these countries and many others, using the medical tourism option will make sense because the claimant can get the best treatment available in his home country at reasonable costs in surroundings that will benefit his recovery and healing, which will allow him to return to work more quickly because being with family during a medical event has proven to be the reason why Latinos have better health outcomes than African-Americans.
By chance, on the third day of the Congress, I met a woman from Guatemala who is working with her American partner on developing medical tourism for self-funded health plans in Latin America. I discussed my paper with her and gave her my business card for her and her partner. They are partnering with Meritain Health/Aetna on creating these plans, and I mentioned to her that Aetna recently purchased Coventry Health Care. I told her it is possible that Aetna could use the work comp services side of Coventry to expand in that direction. Earlier in the day, also by chance, I met a woman from Canada who advises a subsidiary of Blue Cross and Blue Shield of Florida about workers compensation and medical tourism. I gave her my card as well, and sent her my resume and paper by email for her to pass on to her client.
Whether or not any of these two possibilities pan out for me is not really the point I am trying to make. As more and more health care companies implement medical tourism into their plans as options for individuals and groups, and as more and more employers, both self-funded, as well as those who get their health care through the commercial market, the pressure on both insurers and employers to lower the cost of health care as costs keep rising, will no doubt lead them to seek lower medical costs for their workers’ compensation policies as well. What is good for the goose is good for the gander.
But what it will take from the workers’ compensation side is much more difficult than what is already happening among such companies as Google and American Express, both of whom had representatives speak at the Congress about what they are doing with medical tourism for their employee’s health care, as is a company from Michigan who is also using medical tourism for their employee’s health care. With regard to workers’ comp, my paper outlines some of the legal barriers to implementing medical tourism into workers’ comp. Those laws will have to be replaced or amended to open up the workers’ comp arena to medical tourism.
Among some of the issues not covered in my paper, but that present both a problem and an opportunity, are the laws about distance from a claimant’s home a provider can be in order for the claimant to reasonably get to the doctor’s office. This would not be a problem for medical tourism, as the best way it could be utilized would be on a secondary care level. The next problem would be the Employee/Employer choice of doctor requirements states have in their workers’ compensation laws. Here too, this could also be good for medical tourism, if the employer or carrier realizes that local secondary treatment would be extremely costly to both, then finding a lower cost option domestically, or internationally, would allow medical tourism to benefit the workers’ compensation claimant.
Even if a state has laws stating that employees have a choice, like Washington State and Oregon has, then the claimant could choose from a list of providers the state has pre-selected to provide treatment abroad. Washington State already does that with a page on their website that takes you to pdf files that have lists of pre-selected doctors in certain countries. For this to be realized in other states, insurance companies, employers, business groups, unions and even workers’ rights organizations must get involved and lobby their state legislatures to change or amend their laws.
Medical tourism, once the purview of the wealthiest, has become more affordable to more people, as well as to those who are under-insured or uninsured. Self-funded plans and commercial insurance companies are choosing this as an option. For these employers to do so for their health care coverage, and not for their workers’ compensation coverage is like buying homeowners insurance, but not flood insurance or auto insurance. A house is certainly not a car, but neither is it always going to be flooded, but on the off-chance that it is, and it is situated in a flood zone, then it makes sense to buy both auto and flood insurance along with homeowners insurance. Workers’ Compensation should be no exception.
Richard Krasner has worked in the Insurance and Risk Management industry for more than 30 years in New York, Florida and Texas in the Claims and Risk Management spheres, primarily in Workers’ Compensation Claims, Auto No-Fault and Property & Casualty Claims Administration and Claims Management. He has experience in Risk and Insurance Business Analysis, Risk Management Information Systems, and Insurance Data Processing and Data Management. Received my Master’s in Health Administration (MHA) degree from Florida Atlantic University in Boca Raton, Florida in December 2011. I am looking for new opportunities that will utilize my previous experience and MHA degree. I am available for speaking engagements and am willing to travel. Contact Richard or read Richard's blog.
Doctors know where they've been, but they don't know where they're going! Today's medical professionals are strapped to a rudderless ship at sea that's being sucked into a raging storm.
Some politicos would have us believe that the scandalous fifteen-thousand-page Obamacare program (and when, by the way, was the last time anyone you know read 15,000 pages of anything?!) need not be such a shocking insult to healthcare consumers because after all, it helps “less fortunate” people to get medical care.
Steamrollered through an inept Congress, Obamacare appears to have little if anything to do with the realities of healthcare. Instead, Obamacare hints at having everything to do with the crippling economic and personal freedom limitations brought on by the relentless White House pursuit of dictating increased government controls on American lives.
The end result? We will definitely end up with fewer competent physicians.
And those who remain will clearly not be providing adequate care –regardless of competency– because of the restrictions Obamacare piles on top of the restrictions already imposed on them that limit their ability to deliver meaningful health services.
But computerization is what tightens the noose around healthcare necks, some say. Not so. The mismanagement and misappropriation of administrative computerization advances by interfering and uninformed government misfits and ignorant insurance providers is what is at the root of today’s healthcare delivery shortcomings.
The de-humanizing of humanizing services is the characterization that uninformed and manipulative individuals, agencies, and organizations have wrought as they’ve twisted administrative computerization advances into shortcut invasions of patient and physician privacy. Have we lost even having thoughts of human dignity?
When “DOCTOR’S ORDERS” becomes “DOCTORS ORDERS” (as in orders issued to doctors by the White House) to conduct patient gun ownership surveys to build a bigger “Big-Brother-Watching” database universe designed to gain yet more government control, do you think this might possibly get just a bit in the way of doctors performing healthcare services?
Of course EMR (electronic medical records) and EHR (electronic health records) have succeeded at putting patient care over paper care. But are these important advances enough to be really helping doctors to know where they’re going?
And the Internet has fully armed healthcare consumers to be better prepared to understand and manage their own healthcare issues, to be more informed about diagnostics and treatments, and to work more productively with their doctors. But are these advances enough to be able to really help doctors to know where they’re going?
The whole lean organization, lean management fad (where did Quality Circles go?) may be a solution, but is not THE solution. It is simply a band-aid acknowledgement that things have gotten so bad, we can no longer afford for the physician to spare a minute or two extra with each patient and patient family to help heal, and help ensure and reassure a sense of well-being.
More dollars are saved. Care is more efficient. But –at the ultimate point of care– doctors don’t get to spend more time with their patients, so is this increased efficiency really enough to help doctors know where they’re going?
Being preoccupied with efficiency necessitates lower levels of individual healthcare delivery. And last time I looked, healthcare was a profession dedicated to individual care. Perhaps it’s time to redefine the word “care”? The bottom line is that doctors are literally trapped.
Adherence to rules and regulations designed to increase control over their skills and abilities to earn livings commensurate with their training and societal value is squashing the very lifeblood out of healthcare. And Obamacare will surface as the culprit when it’s too late to matter — unless enough small business owners and practice administrators and doctors start to make waves
Don't miss Jonena's addition to the HWR. Gone
are the days when American medicine was ranked head and shoulders above ALL other
healthcare systems around the world. One only needs to watch the up-tick on medical tourism to see that there is a plethora of
qualified healthcare providers beyond our borders. EMRs and EHRs are the US healthcare system’s way of
dipping their toes into 2013. We MUST go beyond getting our toes wet. We need
to implement change methodologies and Lean tools and processes that will guide
all healthcare employees - clinical and non-clinical alike - to participate in
and take responsibility for continuous process improvements within their spear
of influence. Read the entire post.
If one looks at communications revolving around healthcare these days, whether emanating from political, healthcare economics, clinical, or technology spaces, the term patient engagement is invariably found as one of the cornerstones of the conversation. This is no more evident than in the digital health technology space. One would think that patient engagement is only possible by hitching a wagon to the technology horse. I would like to explore the issue with two posts, the first devoted to non-technical considerations and the second examining best practices of technology utilization in this regard.
1. Listen to the patient. Patient-physician communicationis the basis for much of what transpires during the tenure of the professional relationship. Lack of good communication has been cited for medication nonadherence. William Osler, the father of modern American medicine famously stated that the patient will tell you the diagnosis with the narration of the history. Given the fact that most office encounters today last 15-20 minutes and that patients have comorbidities requiring attention, it is no wonder why many times they are not heard. The physician is looking at the computer screen clicking off checks. The system is no longer geared towards human interaction and this creates a recipe for poor care, even if unintended. This is why direct care or concierge medicine is becoming popular. Both physicians and patients are returning to communicating in this setting. Other solutions need to arise to promote communication. Providing patients with pre-visit guidance in order to organize their thoughts and concerns might help.
2. Motivate your staff to be as patient-focused as you are. Office and hospital staff should reflect the provider’s patient-focused approach to care. Many times they are too task-oriented and forget there is a patient who is the reason behind those tasks. If the staff takes on the mindset of a stakeholder in the patient’s care and not just performing a job, the result will be a happier patient. Patient satisfaction surveys (an important part o the future healthcare landscape) will reflect this aspect of the care.Patient-centered professionalism should be the goal of all ancillary staff.
3. Demonstrate to the patient that you are an advocate. Going to bat in front of an insurer for a patient who really needs a specific drug or procedure is something I always felt good about. Spending time on such matters is something physicians years ago (dating myself) went into the field thinking they would have to do. However onerous, it is what patients need docs to do in critical moments. And patients do very much appreciate this. It is what made me feel good going to sleep at night.
4. Show them your personal side. Social media is a great way for providers to show their personal side. This is not to say that personal interactions with patients should take place one on one, but a way in which patients see the personal (and hopefully appropriate) side of their healthcare professional. I believe Twitter is a better forum for this than ‘friending’ between a provider and patient on Facebook.
5. Individualized self-management. Patients will partner with providers in their treatment plans with different levels of enthusiasm. Some patients will require more support than others (motivational and material) and this should be discussed. Discussing patient engagement early on in the relationship is important. It should also involve a caregiver who might be the one participating in the engagement on a larger scale. A provider who embraces co-management and is seen as both a partner and supporter of the patient will be appreciated.
The above might seem obvious to most people, but in today’s discussions surrounding patient engagement, the humanistic aspects of achieving this are lost in the vision of technology magically transforming how patients react to their medical conditions and to their healthcare providers.
David Lee Scher, MD,FACP, FACC, FHRS, is Founder and Director at DLS HEALTHCARE CONSULTING, LLCadvising digital health companies and their partnering institutions, companies, and providers.He is a former cardiac electrophysiologist with over 25 years in patient care. He leverages his experiences as a major clinical trial investigator, human subject research committee chair, Medicare committee member, and medical device industry consultant and key opinion leader in advising clients on best product and business development practices and adoption of digital health technologies He travels worldwide speaking to professional organizations and the general public on topics related to remote patient monitoring and digital health. Board Certified in Internal Medicine, Cardiovascular Diseases, and Clinical Cardiac Electrophysiology, Dr. Scher was a pioneer adopter of remote patient monitoring. He was named one of the ten cardiologists to follow on Twitter and author of one of the ten best healthcare technology blogs. . He is senior medical adviser at Happtique. As chair of Happtique’s Blue Ribbon Panel, he oversees the certification process of health apps.dlschermd@digitalhealthconsultants.com
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images were used.
Our intimate relationships are a lot like our nation’s
healthcare system. Okay, maybe not, but this is, after all, the Valentine’s Day
edition of HWR, so how about if you play along and we pretend to find analogies
anyway?
Dependable, strong, with a firm foundation and a bright
future: If this describes our healthcare
system to you, here’s your heart:
But seriously, for the rest of us, let’s look at what’s
really going on.
Not everyone is enamored with the way our health system is
run today or is looking forward to the changes anticipated by health reform.
Bob Vineyard at Insureblog registers his skepticism
in HIX and ObamaCare where
he sounds unsure
whether the government can deliver on its promises. If you’ve been burned and
are worried about getting burned again, here’s your heart:
More developments on aspects of healthcare
implementation, as Louise at Colorado
Health Insurance Insider tell us that a move to repeal the
health insurance exchange in the Rocky Mountain state fell far short of the
support needed to undo it. Louise writes, "Given all of that, and given the
progress that Colorado has made over the past two years in creating the state’s
marketplace and implementing various other healthcare reforms (both
state-based, like maternity
coverage and gender-neutral
premiums, and
ACA-related, including the recent push to expand
Medicaid), I
would say that Colorado is on track to greatly improve its overall healthcare
outcomes. Efforts to set the state back to square one in terms of reform efforts
are probably politically motivated rather rooted in any real attempts to bring
about real healthcare improvements for the people of Colorado."
Challenges
to Obamacare are wending their way through the courts. Maggie Maher at Healthinsurance.org tells us in her post IRS
ruling a ‘disaster for Obamacare?’ Not quite. The
claim that – as a result of an IRS ruling – “millions” will be left uninsured
under Obamacare is “fear-mongering, pure and simple,” says blogger Maggie
Mahar. In her posts, Mahar rejects the arguments of a February 4 Forbes article
that she says plays right into the conservative claim that Obamacare is "a
disaster."
For the young and young-at-heart, at California Access Health the opinion
on Obamacare is more positive as Anthony Wright tells us that despite
a recent infamous article in Buzzhead, there are some obvious and non-obvious
reasons why Obamacare is a boon to young adults.
For
more on Obamacare, John Goodman at Health
Policy Blog wants to take a balanced approach to health reform and try to
find something for everyone. Here is John Goodman’s piece, Why I Am More Egalitarian Than Most Liberals
on Health Care. John offers
solutions to health care reform that meet the criteria of both liberals and
conservatives.
Do you need help sorting through the fine points of the doc
payment debacle brought to you by the Resource-Based Relative Value System
Update Committee, or RUC, that arcane AMA committee that sets physician rates? Then
here’s your heart, as Dr. Roy Poses over
at Health
Care Renewal explains how the committee is weighted toward
specialists who value procedures and devices
over the cognitive services delivered by primary care physicians. This week he discusses
the negative affect that has on reimbursement rates for PCPs. It’s a thorough
discussion of a difficult issue.
Julie
Ferguson at Worker’s Comp Insiderstates, "A worker's
first day at work shouldn't be his last day on earth." Studies show that
approximately 27 percent of job-related fatalities involve employees who have
been on a new job for less than 90 days. Julie talks about the case of an
untrained temporary worker who suffered a gruesome death on his first day on
the job in a Bacardi bottling plant in Florida.
Also on the labor front, the NLRB has
issued a series of reports based on its decisions in cases regarding employer
regulation of the use of social media by employees. Now that the validity of
recess appointments to the NLRB has been upended by the DC Circuit Court of
Appeals, these – and many other – NLRB rulings are technically invalid. Should
health care employers therefore ignore the NLRB precedents on regulating social
media? David Harlow of HealthBlawgsays no – the
contours of the rules should still be followed in sensible social media
policies.
Over at Disease
Management Care Blog, Dr. Jaan Sidorov warns his fellow physicians
that non-physician professionals and lay-persons are managing to achieve a
remarkable degree of medical expertise. He strikes a neutral tone with this
controversial topic, but in the meantime wonders if "care management" is one
way for consumers to sort it all out.
Disease management, testing and drugs go
hand-in-hand, and at Health Affairs Blog, David Rothman
analyzes studies that show people are unwilling to forgo testing and drugs in
the interest of appropriate utilization, even when experience shows no real
benefit to higher levels of utilization. In his post, he talks about the reluctance of Americans to consider
evidence that certain medical tests and screenings might be unnecessary,
harmful, and not worth the money (although he points out that Americans are
more suspicious of drugs): "When we asked [focus group participants] about
specific recommendations by professional medical societies and the U.S.
Preventive Services Task Force that, for example, women between the ages of 40
and 49 should forgo mammograms or that older men might not want to take a PSA
test, participants were not merely dismissive but disdainful...These kinds of
recommendations, many of them believed, were part of a plot to save money and
they refused to give them credence."
Stretching our Valentine’s Day metaphor nearly to the
breaking point, we ask the question: Is nursing home patient care better when
the nursing home is doing it for the love, not the money? More accurately, do
non-profit nursing homes really provide better care than their for-profit
counterparts? Jason Shafrin at Healthcare
Economist analyzes a study that shows that, when controlled for
proximity to the patient’s home, non-profit nursing homes fare better, using
measures like changes in ADL functioning and hospital readmission rates, than
for-profit nursing homes. For those
nursing homes that aren’t in it for the money, here’s your heart:
You might have other kinds of concerns of the heart. If you
suspect that your loved one is inclined to deceit, perhaps this blog will
strike a chord for you. Joe Paduda in IRS, Health Care Premiums UnderObamaCare and Right-Wing Distortions at Managed Care Matters dissects
inaccuracies in the press accounts of the projected cost of health insurance
under health reform. That
$20,000 price tag for health insurance for a family of four being thrown around
in the press just ain’t so, says Joe. If you’re wondering who might be hiding
something, here’s your heart:
As you’ll see from our next entrant, Brad Flansbaum at the Hospitalist Leader, I had a tough time
deciding who would get the question mark heart. In Blink Twice, Rub Eyes: QI Floaters and Spots, Brad has literally
assembled a collection of snapshots from studies that show how some of our most
touted and expensive efforts to improve patient care are, at best, inconclusive
and, at worst. totally useless. It’s an
impressive collection of unimpressive results. Since Brad’s question mark heart
went to Joe Paduda, I guess we’ll call it a wrap.
From those of us at Healthcare Talent Transformation to all
our fellow HWR bloggers, here’s your heart:
