Hip Hip HIPAA–Myth Busting 101

Photo: starpulse.commythbusters003_m

As far as I am concerned HIPAA has added another layer of useless paperwork on to the backs of physicians, and I particularly resent the cost it has added to primary care.  Therefore, I was excited to see an article on HIPAA myths.  Below is my summary of HIPAA myth bustin’:

Myth 1: You can’t have a sign in sheet.  Yes, you can.  You must limit the amount of patient information on the list.  E.g. don’t have the chief complaint.

Myth 2: You may not say a patient’s name out loud in front of other people.  Again, say the name, but use the minimal amount of information, rather than, “Mrs. Dysmenorrhea, Dr. Strangelove is ready for your pap test.”

Myth 3: Patients may sue you for non-compliance.  No, but HHS (Health and Human Services) recently fined a home care companyfor a major security breach.  Moral: be especially careful with laptops, pdas etc.

Myth 4: Patients are entitled to a free copy of their medical records.  They are certainly entitled to the records, but not for free.  The cost to the patient may include the cost of labor to copy the records, as well as the cost of supplies and postage.

Myth 5: You may not use a fax to send protected patient information.  Not true, grass hopper!  Faxes must be sent to known locations, from secure machines, with the number pre-programmed to reduce dialing errors.  The cover sheet must contain a request to destroy the  information should it go to an incorrect destination.

So, be safe out there.  And yes, we can finally say our patients’ names again.

Advertisements

Don’t Write Off E-prescribing

I may appear to be somewhat of a troglodyte, but I actually have  committed myself to learning to love technology.  I am the proud owner of a smart phone, have mastered my email, and actually use two different EMRs.  So, you see, this qualified me as an expert on EMRs and e-prescribing (wipe that smirk off your face!)

It was with interest that I read “Effect of Electronic Prescribing With Formulary decision Support On Medication Use and Cost” in the December 8/22 2008 issu3e of Archives Of Internal Medicineby Michael Fischer, MD, MS et al.  The authors describe a study in which physicians using e-prescribing with formulary decision support were compared with physicians using traditional paper prescriptions with respect to prescribing tier 1 medications.  When prescribing electronically, the physicians were more likely to choose the lower cost generic tier 1 medication.  There was a 3.3% increase in tier 1 prescribing, with a decrease in tier 2 and 3 prescriptions.  Fischer et al estimate that this would result in an $845,000 savings per 100,000 patients, based on the assumption that each patient filled one prescription per month.

I love saving money, but what was the cost of saving money?  According to the authors, “government estimates of approximate first year costs were $3000 per prescriber.”  In the study, Blue Cross Blue Shield supplied the software to the physicians, along with a free wireless device, access to a secure Web portal, licensing and wireless carrier.  So, the cost was not borne by the participating physicians.

I think as a first step toward an EMR, e-prescribing makes sense.  I do not think that every insurance company should provide physicians with it’s wireless device.  Can you imagine, five different devices for five different insurance companies?!

So what is to be done?  The federal government must mandate one SINGLE e-prescription system that we all should use, and insurance companies should bear the cost, based on percentage of patients enrolled in each plan.  Why should health insurance plans pay?  Because they are the ones that will enjoy the savings!  I think this would be an effective way to usher in the beginnings of an EMR.  Mr. Obama and Mr. Daschle, are you listening?

As physicians, we must look for ways that we can use e-prescribing efficiently and effectively.  We must commit to learning all the bells and whistles, and using it to our advantage.  So, stop hiding behind your prescription pad, and make way for what is inevitable.  Get out there and lobby for what should be done, rather than whining when we get handed the bill for something that will most benefit the health insurance industry!

Win an Amazon Gift Card: What Are Your Goals for Your Practice in 2009?

As a way to encourage goal setting and planning for medical practices, I am hosting a contest.  I will email a $15 Amazon gift card to the person who sends in the best plan for improving their medical practice in 2009.

Here are the rules:

  1. Under the comments section for this post, list the goal your practice will achieve in the year 2009.
  2. Write out the  step by step plan as to how your practice will reach this goal.
  3. Have a time line accompanying each step.
  4. Assign a person  (don’t use their name, but rather “office manager” or “me”  or “book keeper”) who will be responsible for each action.
  5. All goals/plans must be submitted by January 16, 2009 by 12:00 midnight.
  6. I will pick the best goal/plan/action list, and post it on the blog by January 23rd.
  7. I will email the winning entry a $15 Amazon gift card.

That’s it.  No  bull, just good ideas on how to improve medical practices!  I will post my goals for my company, ExtraMD,  by January 8th.

Here’s to some great ideas!

Link Fest: Updates on group visits, RVUs, Medicare and the ‘Physician Shortage’

I’ve been storing up some links and today seemed to be a good time to have at ’em!  They range from the scary (Health Policy and Market) to the fun (the Efficient MD’s slide show.)

Read The Country Doc Report for another take on the group visit.  Country Doc relates how his practice does a group diabetic visit.  He uses smaller group sizes, and describes the three phases of the visit. 

For  an RVU Review, and exactly WHAT the RUC is, and how it effects you, visit Health Care Renewal blog. Boy, did I learn a lot about how we as physicians get paid (or not, as the case may be!)

To increase your understanding of the complexities of Medicare, Medicare Advantage, and Medicare Gap, see Insure Blog.  You may want to have this posted at  your front desk as patients come in with their “red white and blue” cards.

Now there are two types of Medicare plans, Traditional Medicare (administered by the government) and Medicare Advantage Plans (administered by private insurance companies). This has led to an unbelievable amount of confusion.

I love ways to improve my efficiency, and enjoyed the  fun, short  The Efficient MD’s  slide show.  I love his blog, and wish he would post more often!

For a chilly take on the role of physicians in the future, visit The Health Policy and Market blog.  According to the blog, we have plenty of doctors, and a “federal physician workforce policy” should be in place.  Just what I want, the federal government interfering even more into the business of health care! 

Establish a federal physician workforce policythat achieves the goals of organized care. TDI research has shown that the U.S. does not need more physicians; we have enough to care for America’s needs well into the future.

Let me know YOUR favority business of health care posts and I’ll put ’em up!

Walk the Talk: the Patient Encounter

I am fascinated by how we physicians communicate (or not) with each other and with our patients.  As a medical student and resident NO ONE ever thought about how physicians communicated with patients.  We were always so focused on nailing the disease process and treatment that the patient was nearly ignored.  I don’t think I had a single attending that excelled in talking and listening to patients.  I have tried to self educate (isn’t that what most of medicine is?) and found a thoughtful curriculum for residents on line, from the University of Washington.  I will reproduce the salient points here:

  1. Have an opening introduction: “Hi, Mrs. Marlboro, I’m Dr. Pookie.”  (Hand shake, sit down, look at patient.)
  2. Allow the patient to complete their opening statement.
  3. Attempt to get the patients full agenda: “Mrs. Marlboro, what is the most important thing we need to work on today?” At this point, prioritizing the patients concerns is key.
  4. Set the ground rules: “Mrs. Marlboro, it sounds like stopping smoking is what we should focus on today.  Is that right?”
  5. Gather information, with a  mixture of open and closed ended questions.  Summarize and clarify with out interrupting.
  6. Actively listen, using non verbal cues as well as verbal cues.  (“Uh huh, ah…”)
  7. Explore their beliefs about the illness.  (Yes it’s hard to keep your mouth shut when a patient insists that smoking isn’t bad “because, Doc, I know you’ve heard it before, but I don’t inhale.”  Just heard this from a diabetic as he went on his way to the cardiac cath lab…  But try!)
  8. Acknowledge the patients feelings/values.  (“Yes, quitting smoking is really hard, even our President Elect thinks so.”)
  9. Share information in terms that patients understand.  (Save the free radical talk, two gene promotor theory of cancer for some one who cares.)
  10. Encourage questions: “what questions or concerns do you have?”
  11. Reach agreement on the treatment plan, actively encouraging patients to participate in the plan. 
  12.  IMPORTANT: TRY TO GAUGE THE PATIENTS WILLINGNESS  AND ABILITY ENGAGE IN THE TREATMENT PLAN!  The best plan in the world is worthless if the patient can’t/won’t follow it!
  13. Provide resources (hand outs, referrals etc.)
  14. Realize you can NOT cover every item at every visit. 
  15. Close the encounter by summarizing the treatment plan and setting up the follow up plan.

The patient encounter needs to be a balance between “patient centered skills” and “agenda setting skills.”  Interestingly, when a patient is dissatisfied, they underestimate by 8% how much time the physician spent with them, while if they are satisfied, they overestimate the time the physician spent with them by 20%!

Please see link from Society of General Internal Medicine below.   First author is Matthew F. Hollon, M.D., M.P.H., from the University of Washington. 

http://sgim.org/userfiles/file/AMHandouts/AM08/WC01%20Matthew%20Hollon.pdf

Medical Practice as a Socially Responsible Business

I have searched for a way to describe my view of medicine as a business.  I finally realized that the practice of medicine should be classified as a socially responsible business.   “Who cares?”, you say.  Well, I say we all should care.  We went into medicine to help people.  However, as I am fond of saying, we can’t help people if we don’t keep the doors open.  We need to have a way to do both.

So how to reconcile the two visions?  We have the altruistic Norman Rockwell picture of the benevolent physician examining a young girl’s doll directly opposing today’s appointment packed, hyper regulated, law suit filled world.  I propose we view our practices as socially responsible businesses.  So what does this mean?

  1. Owners of socially responsible businesses realize that making money is important.  Practices need to stay in business, pay their employees a competitive wage and make a decent living for the physician owners.
  2. Owners of socially responsible businesses realize that as a practice grows, non-financial benefits grow.  You CAN see patients who can’t afford to pay, or can only afford to pay a little if your medical practice/business is financially fit.
  3. Owners of socially responsible businesses realize that non-financial benefits have financial costs.  The socially responsible business may have to absorb higher costs and accept smaller profits.  NOTE: I didn’t say run the business as a charity!  By definition a business is NOT a charity!
  4. The socially responsible businesses/medical practice has at it’s core a mission to provide quality health care AND stay in business.  The two are NOT mutually exclusive, but must intertwine and co-exist.  One must feed the other.
  5. Government intervention and big business are not appropriate business models for socially responsible medical practice/businesses.  Physician owners must start from the ground up and build a profitable, socially responsible business model that DOES NOT involve government intervention.  Additionally, the typical frenzied profit taking by big businesses is not an appropriate model either.
  6. The socially responsible business/medical practice must seek efficiencies where ever possible.  Creativity is a core value of the socially responsible medical practice/business.
  7. The socially responsible business/medical practice avoids “short termism” and “poor governance and regulation, misaligned compensation and incentive systems, lack of transparency, … poor leadership and a dysfunctional business culture.”  (Quote from Al Gore, http://www.careerjournal.com/article/SB122584367114799137.html)  This means that the physician owner is in the medical business for the long haul, and has a clear vision as to where the socially responsible medical business/practice should go.  It means the physician must learn HOW businesses operate, and how to manage the practice in a long term sustainable fashion.
  8. The socially responsible business/medical practice behaves as if people and place matter, because they do.
  9. The socially responsible business/medical practice believes that time is money.  Therefore, it doesn’t waste the time of patients or physicians.
  10. The socially responsible business/medical practice embraces technology, but realizes that government mandates to REQUIRE technology will drive the socially responsible medical practice/business OUT of business.

For more resources and thoughts on the socially resonsible business of medicine, see www.bcorporation.net  View the declaration of independence on “b corporations” at:  http://www.bcorporation.net/index.cfm/fuseaction/content.page/nodeID/9e7f627c-487b-41f1-975b-5adfeceffbb4/  See also Ode Magazine, December 2008, pages 21-25.)  This issue is not yet available on line, but website is www.odemagazine.com.  I have no alliance with the B Corporation.net, or Ode Magazine.

Survival Tips for Primary Care: How to Save Money

Now that I have vented/ranted/opined on the demise of primary care, let’s move to some survival tips. Following are PookieMD’s two fundamental. most important, and most loathsome rules of survival in primary care medicine.

The money is in the numbers.

Time is money.

Yes, you have to see patients to  make money, and given today’s reimbursement you have to see a fair amount of them.  This is a given, a fact, a law.  If you don’t want to see 20 (or more) patients a day, go in to psychiatry.  If you are in primary care, you probably are looking for a way to make a dollar go a bit further.  Don’t laugh, you might spot something useful here!

  1. Get a set back thermostat.  No, these aren’t just for home use.  If you are paying your utilities, why are you heating the office at night? 
  2. Learn to be efficient.  I have previously blogged on being efficient.  Running yourself ragged to see more patients is a recipe for burn out (if you are not already there!)  Look for ways to become more efficient.
  3. Use your EMR to the fullest.  For heaven’s sake, if you bought the thing, use it!  Learn every bell and whistle it has, every dot command, every work around, every reminder system. .  It will make you more efficient. Reminder: USE the perscribing feature (CMS will be rewarding this, and then penalizing you if you DON’T use it!
  4. If you don’t have an EMR use preprinted check box forms when possible. Write in the extras but the check box forms will save you time, and are usually more legible.
  5. Have your receptionist call and remind patients of their appointments.  An empty slot in your day doesn’t generate revenue.
  6. Look at how you use your space.  Could you rent a spare exam room to a occupational or physical therapist?
  7. Consider extended or weekend hours.  You are paying the rent whether you are open or not.  Consider opening a half day on Saturdays for urgent care appointments.  Don’t let Walmart take away YOUR business!
  8. Consider using medical assistants during their internship.  Lots of local MA schools are looking for practices that will take on a student.  These students are usually in the later part of their training and can extend your man power for free!  Beware, your nurse or MA should supervise them.
  9. Make sure you are billing for in-office procedures.  Train your staff to check off ua’s, strep tests, pregnancy tests etc.  You should then double check when you are filling out the superbill. You are doing ’em, get paid for ’em.
  10. Shop at big ware houses, like Costco.  Get toilet paper, and office supplies at a discount.
  11.  Make sure you charge for vaccination admission and the vaccine itself.
  12.  Use those freebie exam table coverings.  (Yeah, I’m not fond of laying down on an exam table with a paper covered with Viagra logos, but hey, what a poor primary care doc to do?)
  13. Don’t buy new–buy used equipment when possible.  (Checked Ebay lately?)
  14. Consider remote deposit capture.  If you have a big enough volume of checks that come in, you can scan and electronically send the images to your bank to get instant deposits. Cash flow is king!
  15. Consider ancillary services.  See previous post on ancillary services.  See what you can stomach.
  16. Consider group appointments.
  17. Utilize your staff to the fullest.  See previous rants.  Yes, I’m talking to you.

Look, this stuff isn’t fun.  However, if you want to survive, your business (note, I didn’t say PRACTICE), must have revenues greater than expenses.  This is the law of keeping the doors open.  Maybe things will change for the better.  Maybe not.  But if you are doing primary care, it’s up to you how you handle your BUSINESS, and how you keep the doors open so you can see patients.