The Senate healthcare bill does not include a new surtax on the wealthy that House Democrats' legislation relies on to offset costs of overhauling the system. But Senate Democrats have their own taxes that are stirring controversy and likely to be at the center of debate, the Wall Street Journal reports. Senate Majority Leader Harry Reid made a late change to his bill by adding an extra Medicare payroll tax, which would generate $54 billion over 10 years according to the Congressional Budget Office. Under the plan, wages over $200,000 for single people and $250,000 for married couples would be subject to a 1.95% payroll tax, up from the current 1.45%.
Chances of business supporting the Obama administration's health overhaul are fading fast after Senate Majority Leader Harry Reid's bill took a liberal turn, the Wall Street Journal reports. The Obama administration has courted small businesses from the start, and at times executives have shown favor toward Democratic plans such as the bill passed by the Senate Finance Committee. But now several industry groups are banding together to ask Congress to scrap the current bills and start from scratch on a health overhaul, saying the public plan included in Reid's bill will pay lower rates and shift costs to those with private insurance.
According to a study conducted by Google, 86% of doctors have gathered health or drug information online, and the Internet is used more than peer review journals, CME courses, or any other source for finding this type of information. Search engines are the most common method for finding health resources, and most doctors click on the top result in the search, the study found.
Editor's note: The following article is adapted from HealthLeaders Media's new book, Orthopedics and Spine: Strategies for Superior Service Line Performance. For more information, visitwww.hcmarketplace.com.
The number of patients needing healthcare, especially orthopedic services, is growing quickly; however, the number of orthopedic surgeons to care for them is not keeping pace. Orthopedic coverage in EDs is at risk in many hospitals. Each day, more and more hospitals are paying doctors to be on call. With margins below the 2.5% level for many hospitals, this becomes an additional burden.
Despite a wealth of uncertainty, several things are for sure. Hospitals and surgeons will be asked to do more with less. Costs must be reduced while quality improves. Transparency will become mandatory. There will be winners and losers.
Those who accept the status quo and cling to the broken system of the past will not be the winners. The community hospital and its physicians must create a product and brand equal to or better than that of its larger competitors. It won't be enough for them just to think or say they are excellent; they will be asked to demonstrate their results. All the government can do is provide us with the right incentives. It cannot transform healthcare. That can be done only by those of us in the trenches.
Outlook for surgeons
Surgeons will at least be able to count on having plenty of patients. For joint surgeons, the loss of reimbursement has been significant. In 1978, a total joint replacement reimbursement was $5,000. In 1994, it was reduced to $2,100, and by 2007 to $1,280. Whether surgeons will be fairly compensated and can increase their efficiency to handle more patients is unclear.
Given the economic pressures the country is facing, surgeon reimbursement is likely to decrease in real dollars rather than rise. Affected by this decline in reimbursement, surgeons will continue to find other avenues of income, such as surgical hospitals, ambulatory surgery centers, MRI, physical therapy, orthotics, and prosthetics. Providing these profitable services once provided by the hospital has created more stress on the hospital margins. Hospitals have asked the government to curb this activity. Just when we need closer physician-hospital relations to solve our issues, we have increased tension.
Patients will continue to expect perfection from surgery. They feel that if we could put a man on the moon, we should certainly be able to provide nearly perfect healthcare. Physicians are held to a very high standard to do just that, and if they do not, they often find themselves in court. It is also unlikely that Congress will enact any significant tort reform, meaning that very costly defensive medicine and high malpractice premiums will continue.
With all this turmoil, many excellent orthopedic surgeons and large groups are now opting to become employed by hospitals. Compensation is usually based on relative value units worked. Employed surgeons still have significant governance in day-to-day practice decisions. I have observed this working quite well in many places. Goals can be more easily aligned. The orthopedic practice that I founded in 1977 has chosen this route. With the expected shortage of surgeons and national policy changes, this may be the best option for both parties. Whether employment becomes a success story for all involved will not be known for several years.
The traditional model
One of the major flaws with traditional medicine is that we don't have a comprehensive system of coordinated patient-centric care. We have an "it depends" medicine. With specialization (a good thing) has come fragmentation. Everyone operates within silos. Primary care doctors have their systems and set of beliefs, as do surgeons, anesthesiologists, professional staff members, and so on. From their viewpoint, the care they are giving is excellent. However, this individualism, which to date is sacrosanct in healthcare, leads to multiple plans of care for the same condition.
Consider that for a procedure as straightforward as a total joint replacement, there could be as many as 10 care plans for a patient in the same hospital, depending on which professionals are involved. Having that many choices is not a good idea, even if they are evidence based. Operating within these silos can be costly and potentially harmful to the patient. It reduces efficiency for the staff while increasing the risk of error.
Tomorrow, with transparency and access to knowledge, patients, employers, payers, and physicians will be able to find out who has succeeded in making this transformation.
They will seek out those institutions and physicians that can demonstrate superior performance. Patients will drive past one hospital after another to seek care at these institutions. Physicians and nurses will seek them out as the best places to work. They will become branded as destination centers.
Surgeons are beginning to realize that their reputations are tied to the hospital/patient/family experience. Therefore, it is vital that they improve the care and experience of patients. Hospitals and surgeons must create a common vision for great patient care. One solution that has proven itself very effective is to create sophisticated service lines, which we like to call destination centers of superior performance. We take the best of traditional care and management—highly trained and qualified people—combine it with the needs of our patients—great experience and outcomes—and build it into a system of care. This is done by having the physicians and hospitals come together to create systems that are patient-centric and cost-effective.
The service line approach to orthopedic care represents a huge opportunity to resolve these challenges and more. "Service line" is a term borrowed from manufacturing industries that promote product lines. Similarly, hospital service lines seek to organize care delivery by disease processes, assemble dedicated clinicians and staff members to handle the entire care process, and coordinate with overlapping service lines.
Opportunities abound
Service line development in musculoskeletal care is the perfect place to start. Primary hip replacements are expected to increase in demand by 174% by 2030, and primary knee replacements by 673%. Hip revisions are expected to increase by 137%, and knee revisions by 600%. Nationally, back and neck pain represent the second most frequent reason patients see a doctor (the first is the common cold). More than 13 million people annually visit physician offices for back pain.
Chronic back pain accounts for 15% of all sick leaves and is the leading cause of adult disability.
New surgical technologies for the spine have enabled this market to experience over 10% growth per year during the past decade. Geriatric fractures are on the rise, and many can be prevented. Sports medicine, a term used only as a marketing tool when I started practice, is now the preferred path for young orthopedists and patients to provide and receive care. Foot/ankle and hand centers are being created as well to provide patients with more comprehensive care.
Even in today's fast-changing, increasingly technological world, the principles of leadership, excellence, management, patient-centric care, measuring results, and process improvement will endure.
This article is adapted from HealthLeaders Media's new book, Orthopedics and Spine: Strategies for Superior Service Line Performance. For more information, visitwww.hcmarketplace.com.
Because of their relatively small size and close working relationships, physician practices are less likely than larger healthcare entities, such as hospitals and nursing homes, to find themselves in an employment suit.
However, employment suits do happen, and practices should watch for the following employment mistakes to reduce their likelihood:
1. Failure to properly pay nonexempt employees for breaks, lunch, and overtime training. "This is a ripe area for litigation right now," says Cherie L. Silberman, attorney at Florida-based Constangy, Brooks & Smith, LLP (CBS).
2. Inappropriately classifying hourly employees as salaried employees to avoid overtime and other compensation. Just because you slap an "assistant to the assistant manager" title on somebody's name tag doesn't make him or her exempt from overtime and other benefits. Juries salivate over this issue. CBS attorney Michael D. Malfitano recommends that physician practices undertake annual or biannual audits to ensure that they haven't improperly classified employees as exempt.
3. Failure to implement, disseminate, and follow personnel policies. What are your harassment and discrimination policies? What are your corrective action and disciplinary policies? You might have the most progressive and comprehensive personnel policies in the business, but they're useless if you don't follow them.
4. Failure to train employees. Do your employees understand the finer points of the Americans with Disabilities Act? Do they understand that harassment is not limited to sex, but can include religion, age, race, ethnicity, disability, and marital status? This training should apply to all supervisors and managers, as well as HR.
5. Failure to document promptly and accurately. Prepare every document regarding warnings, complaints, and disciplinary action as if it is being introduced at trial and you are the jury. Be objective. Get the facts, not the conclusions. The document should include the date it was created, the name and signature of the author, the name and signatures of the witnesses (when applicable), and the stated purpose of the document.
6. Failure to appropriately evaluate employee performance. Make sure your assessment of your employees is accurate. Don't fudge over the problem areas because it's difficult to refute a former employee's complaint of being wrongfully denied a promotion after a soft-hearted supervisor gave a glowing, but undeserved, appraisal. "If they make a decision adverse to that employee later on because of poor performance but there is no documentation to support that, that could look like discrimination," Silberman says.
7. Failure to adequately discipline employees. Remember, the purpose of the discipline, beyond covering your own liabilities, is to help the employee improve. Juries really dislike it when they believe that employees are blindsided with punitive actions.
8. Failure to conduct thorough investigations into employee complaints and, if necessary, take prompt remedial action. If an employee tells you he or she is being harassed, look into it immediately. Again, this is not a difficult concept, but some employers hope to avoid confrontation at all costs, often to their own detriment. Establish ground rules for the interviews, including providing the employee with an explanation about the complaint. Don't make judgments or draw conclusions. Make sure the employee answers the questions posed; listen carefully and take notes.
9. Failure to correctly designate absences under the Families and Medical Leave Act (FMLA). Eligible employees can take up to 12 weeks off under FMLA at companies with 50 or more employees if they have been employed there for at least one year, including 1,250 hours in the previous 12 months. Eligible categories include the birth of a child, placing a child for adoption or foster care, caring for a close relative with a serious health condition, and the employee's own serious health condition. This probably won't affect many of the smaller physician practices, but it's still a good idea to be aware of the law.
10. Failure to prepare for foreseeable employee terminations. If you see an employee that might be a good candidate for termination, plan for it. Document your case for termination. Provide that employee with the necessary notices, releases, and waivers. Determine whether the employee is in a protected class and ensure that the termination is not discriminatory. Make sure the fired employee's severance and vacation pay is ready and accurately assessed at the time of termination.
This article was adapted from one that originally appeared in the November 2009 issue ofThe Doctor's Office, a HealthLeaders Media publication.
Senate Majority Leader Harry M. Reid presented an $848 billion healthcare overhaul package that would extend coverage to 31 million Americans and reform insurance practices while adding an array of tax increases. The Senate measure is similar in scope to legislation the House approved earlier in November. It would require most people to buy insurance, and if their employers did not offer affordable coverage, they would be able to shop for policies on new state-based "exchanges" that would function as marketplaces for individual coverage. Insurance companies would have to abide by new rules that would ban practices such as denying coverage based on preexisting conditions.