The ousted leaders of a California healthcare workers union say they will found a labor organization to rival their former parent union, the Service Employees International Union. The announcement came the day after SEIU President Andy Stern in Washington, DC, wrested control of Oakland-based United Healthcare Workers-West by removing its 100 officers and placing the local under a trustee's care. Sal Rosselli, former president of the 150,000-member local, said it is too early to say who will lead the new national union and how long it would take to get it up and running.
In a letter to the Boston Globe, Joseph Biederman, MD, a Massachusetts General Hospital psychiatrist, says that a drug company gave congressional investigators inaccurate information about a payment in 2001. U.S. Senator Charles E. Grassley's office had said that Johnson & Johnson gave Biederman $58,169 in 2001, but the psychiatrist said that he earned just $3,500 from the company that year. Most of the amount of the check, $50,000, was deposited into a hospital account to support a scientific conference, "which was mistakenly assigned to my Social Security number," wrote Biederman.
Hospital patients are rarely able to identify their doctors by name or to describe their roles in the patients' care, a new survey by researchers at the University of Chicago has found. Researchers interviewed 2,807 adults admitted to the school's hospital over a 15-month period. The patients were asked about the roles of the various physicians attending to them and to name the doctors on those teams. Some 75% of the patients were unable to name a single doctor assigned to their care. Of the 25% who responded with a name, only 40% were correct.
Providers, practice administrators, and office staff members should be well versed in the basic components of the revenue stream to maximize revenue while staying within compliance guidelines.
To keep a close watch on revenue, practices must take the following steps:
Review unbilled charges daily. Failure to send claims out on time may result in lost revenue and a sluggish cash flow. However, it's not uncommon for a billing department or service to delay billing while awaiting completion of the following:
Insurance verification
Operative report
Clarification of CPT or ICD-9 codes
Missing CPT or ICD-9 codes
Missing modifiers
Capture all services rendered. Encounter forms, paper and EMR-based, should be updated at least annually. The most efficient way to accomplish this task is for billing personnel to meet with providers and take these steps to verify that all services rendered are captured through appropriate codes:
Add new CPT and ICD-9 codes that are relevant to the practice
Remove deleted CPT and ICD-9 codes
Verify that all modifiers used by the providers are on the form, including those pertinent to new services
Verify that codes for all new and existing services are included
Revise fee schedule annually. Most third-party payers issue a new fee schedule annually. Therefore, practices should check their fee schedules to make sure they bill above the allowed amount of the highest third-party payer billed. Staff members must also ensure that charges are paid correctly according to the fee schedule.
Keep your eye on the denials. One of the best ways to maximize revenue is to have claims paid the first time they are submitted. Once a claim is denied and has to be corrected and rebilled, the practice is not only paying office staff for this extra work, but the cash flow is slowed down.
Editor's note: Ruth Dolby is president of Dolby Healthcare Consultants, LLC, in Stoughton, MA. Contact her at 781/341-9459 or by e-mail atruthdolby@aol.com. This article was adapted from one that originally appeared in the January 2009 issue ofThe Doctor's Office, a HealthLeaders Media publication.
The uninsured. The underinsured. Employers offering little or no health coverage. Employees unable to pay for health coverage when it is offered. Disparate technologies. Increasing numbers of people with chronic illnesses. These are among the forces that have come together to form healthcare's perfect storm.
Every year, the McKesson Health Solutions Leadership Forum brings together top healthcare experts to share their views of the industry's future. While all have differing viewpoints, at the 2008 forum they agreed that the healthcare system must change to be effective in the future.
The discussion focused on the many factors that impact healthcare:
The United States spends $2.5 trillion annually on healthcare, and the total growing every year.
Chronic diseases limit the lives of 25 million people in the U.S.
In 2006 and 2007, 90 million people were uninsured for some or all of the year.
Many businesses that offer healthcare coverage pass increases in premiums on to employees, who sometimes must opt out of coverage so they can afford to pay the rent or mortgage, or purchase food or gas.
Technology is often hailed as a solution. Savvy patients use e-mail, blogging, and social networking to learn and discuss chronic and acute health conditions, but many providers still use pen and paper to write prescriptions and enter information in charts. Providers who do use technology are stymied by software that doesn't "speak their language."
In today's world, patients want healthcare managed instantly and often prefer quick-fix medications or surgery to address problems like obesity or diabetes, rather than getting to the root of these issues through prevention or management.
Healthcare is "held hostage by cultural factors that we don't know how to affect," said Emad Rizk, MD, president of McKesson Health Solutions, at the forum.
Denmark's medical home program
One solution discussed at the forum comes from Denmark. In Denmark, a successful medical home reaches beyond the physician's office and includes the patient's community.
"A strong primary care system is essential to achieving a high performance healthcare system, which leads to better health outcomes. Patients report better coordination among various physicians if there is a medical home," said Melinda Abrams, senior program officer for The Commonwealth Fund.
Danish patients manage their care with 24/7 access to the provider/medical home, personal health records, and more.
Physicians are paid for telephonic advice, and paid more if the patient settles the issue by phone. A report is e-mailed to the patient's primary physician the next day. This has led to country-wide physician cooperatives that provide patients with 24/7 phone support and providers with around-the-clock access to patient medical records.
"We must get the patient's perspective to have a successful medical home. Let's learn from other countries," Abrams said.
Rebuilding the primary care model
Healthcare is currently an "enterprise"—one that has not delivered on the promise of quality and cost efficiency, said Douglas Henley, MD, executive vice president and CEO of the American Academy of Family Physicians. "We need a revolution to make a healthcare system that can and will deliver on this promise. The primary care patient centered medical home is the cornerstone to healthcare system reform."
Practices should be designated as medical homes to ensure that all physicians within the practice buy into the medical home concept and that the patient is the center of the care continuum. The patient-centered medical home is a "framework for organizing systems of care at both the practice and society level," he said. "This is culture change. It is about creating some chaos before improvement."
Higher payments for the primary care physician will be necessary. The existing physician payment system must evolve into one that includes an updated fee-for-service schedule, incentives for quality improvement and performance assessment, and care management fees. The extra money will come from the savings created through better patient care management, including fewer hospitalizations and ED visits, and unnecessary testing.
All 280 providers at the Billings Clinic in Montana have re-oriented the practice, making it better for patients and staff. "Culture is important. Physicians need to look at the end of the year to see how they've done for all patients," said F. Douglas Carr, MD, medical director of education and system initiatives at Billings Clinic. "The care is organized by a team, but it has to be done in a 21st century way."
The clinic uses an electronic medical record to reduce variations among different units. While some physicians have issues using the EMR, this is more an indication of a broken process, rather than a problem with the EMR itself. "Our process was flawed on the paper versions as well, but it was less obvious," he said.
Advancing the medical home: government and employers
As assistant secretary & Medicaid director for the North Carolina Department of Health and Human Services from 2005-2007, L. Allen Dobson, Jr., MD, developed Community Care of North Carolina with the goal of improving quality and controlling Medicaid costs.
The program's four objectives were to:
Improve the care of the Medicaid population while controlling costs
Develop community networks capable of managing recipient care
Develop systems to improve the management of chronic illness
Fully develop the medical home
Now vice president of the Carolinas Healthcare System, Dobson said that the key to the program's success was establishing a medical home. To work, these programs must be community-based to ensure that patients continue to receive care from the same doctors and providers. "Doctors don't mind seeing them, but they don't want it to be more difficult," he said.
Results of the program include fewer hospitalizations and ED visits. "This is important because this is where most of the avoidable money is spent," Dr. Dobson said.
Employers face many similar challenges—members with poorly controlled chronic illnesses—but the approach is different. Terry McInnis, MD, medical director for health management innovations for GlaxoSmithKline, said public and private employers seek coordinated, easy-to-use healthcare for their employees.
"Employers want to provide high-quality healthcare, but instead the system is splintered," she said. A high-quality model needs to help the obese, those with poor health habits and those with a multitude of chronic conditions. Unfortunately, these same consumers get episodic care through a rushed office visit. "Nobody's talking with each other in the system. As payors, we can't afford that cost," she said.
She sees an increase in interest from CEOs who want to impact a company's bottom line as healthcare costs skyrocket. "Employers should remove barriers to preventive care and management of conditions for those patients who take charge of their health. The key words here are 'who take charge of their health'—each of us must take responsibility for our own health. That is 'consumer engagement,'" she said.
Healthcare in the future
The medical home will be successful, but it won't look the same or even have the same name. Today, we have "medical home 1.0. It will be Medical Home 3.0 that emerges with some stickiness. Everybody wants to do the right thing. There's a calling in the healthcare system that's noble," said Paul Keckley, PhD., executive director for the Deloitte Center for Health Solutions.
Keckley believes that by 2017 a number of drivers will push the industry:
Pressure of policies and politics
Connected care anywhere
More transparency
Multiple, convergent relationships
Technology companies delivering suites of solutions for data
The only thing we know for sure is that healthcare will be much different in the future than it is today.
Some changes we expect to see include:
Reimbursement changes that will transform the role of primary care providers.
Increased focus on care management strategies.
Performance-based payment for providers and punitive payment for "never" events.
New care models using technology and a convergence of healthcare services similar to retail clinics
New technology adoption after undergoing provider scrutiny.
Information technology seamlessly combining data and workflow.
"We expect the current model to change and likely include significant advances in and acceptance of technology; new models of provider reimbursement; new and changing roles for healthcare professionals; and other innovations yet to be created," said Rizk.
Jim Hardy is senior vice president and general manager for McKesson Health Solutions. Diana Verrilli is vice president of business development and marketing strategy for McKesson Health Solutions.
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In many ways California is nothing like the rest of the nation. Its massive economy, changing demographics, and unique healthcare environment make it difficult to draw comparisons if you're, say, a physician practicing in rural Missouri.
So when the rest of the country reads about California emergency room doctors filing a class-action lawsuit against the state over low reimbursements and a failing safety net, it is tempting to dismiss it as an isolated problem. After all, California ranks last in emergency departments per capita, according to a report card from the American College of Emergency Physicians, and has one of the worst emergency care networks in the United States.
But the underlying challenges that prompted the lawsuit are not unique to the state by any means, and it may be better to think of California as a bellwether than an anomaly.
The problem boils down to reimbursement. California has some of the lowest Medicaid reimbursement rates in the nation, and in 2007 alone emergency physicians subsidized more than $100 million in services to Medi-Cal patients because of payment disparities.
Last year, physician groups stopped a proposed 10% reduction in reimbursement levels (sound familiar?), but state officials have proposed another $1.1 billion in Medi-Cal cuts as an attempt to balance the budget.
The consequence of years of financial struggles has been the closure of more than 55 emergency rooms during the last 10 years. And as specialists increasingly opt out of call coverage assignments, and patients continue to use the emergency room for nonemergency treatment, those that remain open are backed up and overworked.
These problems may be magnified in California, but they are familiar to emergency physicians everywhere. And they will only get worse.
"The state's record high unemployment rates, reduced rates of insured patients, and the challenges of the overall economy are only exacerbating this situation," said Steve Maron, MD, president of Valley Emergency Physicians Medical Group, one of the practices represented in the suit, in a Business Wire article. "With access to primary care shrinking, Medi-Cal patients increasingly must turn to emergency departments for care, further straining the system."
So in a desperate attempt to find a solution, the state's physicians have turned to a lawsuit. It's difficult to see how this will accomplish anything, other than prodding California to shift some funds around to fuel a broken system. Perhaps its real value is simply as an indicator of the severity of the problem.
In the short term, Medi-Cal needs funding, and the lawsuit can't correct for a budget shortfall. There may be a glimmer of hope in the federal stimulus package, which promises $87 billion to help states share Medicaid costs, currently making its way through Congress.
But as my colleague Philip Betbeze points out, that is nothing more than a Band-Aid on a gaping wound. What emergency physicians in California—and across the country—really need is a fully-funded physician reimbursement system, a primary care network that keeps patients out of EDs, and a solution to the growing number of uninsured patients.
Those are elusive goals in normal times, and all the more difficult in a recession. So in the meantime, we're left with Band-Aids and lawsuits, neither of which addresses the real problems.
Elyas Bakhtiari is a managing editor with HealthLeaders Media. He can be reached at ebakhtiari@healthleadersmedia.com.
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