A study of the quality of care given by doctors while the pay-for-performance incentives were rolling out in Massachusetts shows they didn't make a difference. Researchers from Massachusetts General Hospital, Harvard, Harvard Pilgrim Health Care, and Massachusetts Health Quality Partners report that clinical quality got better in Massachusetts between 2001 and 2003 across the board. They studied doctors groups whose income was tied to a series of measures, such as how many patients got mammograms or had their diabetes monitored.
In an ideal world, you'd be able to hire an experienced professional marketing director to manage your program—that is if your practice is large enough and has room in the budget.
But if someone else handles marketing development, such as a physician, a practice administrator, or another executive, it is vital that the person is able to devote the appropriate time to the job. Ideally, this is an individual who understands the importance of relationship building and customer service. This individual will make sure that physicians are on time for appointments and that they follow up appropriately with referring physicians.
This is not an operations-only issue; it is a serious part of customer relations that can make or break a group practice.
"It's their job to find out what it is the patient needs," says Patrick T. Buckley, MPA, a healthcare marketing expert with more than 25 years of experience in the field. "Sometimes the follow-up is lacking."
One of their first goals should be to develop a marketing budget.
The budget is an expression of the manner in which the marketing program seeks to achieve its annual goals. It supports the group's ability to deliver needed clinical services to its patients. The budget must be adequately sized and appropriately spent to enable the group to rise above competitors who may offer similar services.
Consider the following factors when sizing your budget:
What are the practice's clinical growth goals?
What specific resources are required to attain those growth goals?
How much money must the practice spend to counter its competitors' efforts?
Depending upon the size of the group, the marketing manager may or may not have the ability to employ additional marketing staff members.
In comparison to hospitals, most physician groups have modest marketing budgets. The marketing director must make every cent count by determining what can reasonably be accomplished with the existing resources versus what will need to be outsourced.
This article was adapted from one that originally ran in The Doctor's Office, a HealthLeaders Media publication.
For the last 15 years, Merritt, Hawkins & Associates has been reporting on the salaries offered to recruit physicians, and our most recent Review of Physician and CRNA Recruiting Incentives reveals an interesting new development. In the last year, salaries offered to recruit certified registered nurses anesthetists (CRNAs) were higher than salaries offered to recruit primary care physicians. On average, CRNAs were offered $185,000 a year, compared to $172,000 for family practitioners. CRNAs also were offered more income, on average, than general internists, pediatricians and hospitalists.
The fact that nurses (albeit it those with advanced training) are paid more than some physicians is eyebrow raising and has sparked a good deal of heated online discussion. Some physicians argue that CRNA salaries demonstrate how relatively poorly doctors are paid, while non-physicians maintain that the six-figure salaries doctors earn are nothing to complain about regardless of what CRNAs make.
Do physicians who maintain that they are underpaid have a case? Or should doctors be happy with their current earnings?
First, consider average salaries being offered to physicians in various specialties as reported in Merritt, Hawkins' 2008 Review:
Orthopedic surgeons: $439,000
Radiologists: $401,000
Cardiologists: $392,000
Urologists: $387,000
OB/GYNs: $255,000
Psychiatrists: $189,000
Hospitalists: $181,000
General internists: $176,000
Family practitioners: $172,000
Pediatricians: $159,000
One point brought home by these numbers is the striking disparity between the pay of primary care physicians and surgical and diagnostic specialists. Current payment systems reward physicians who perform procedures at a higher rate than physicians who employ cognitive and consultative skills. This is one reason why fewer medical school graduates are choosing primary care, fueling a shortage of primary care doctors that some observers feel could soon reach crisis proportions.
Independent of disparities between specialists, most physicians earn upper middle class incomes, while a few doctors are outright millionaires. Apparently, some people are not happy with this state of affairs, since the pressure to cut physician reimbursement is unremitting. The government and private payers wouldn't find cuts quite so easy to impose if the public at large objected. There is little demonstrable outrage, however, over declines in physician reimbursement.
Maybe there should be.
Many doctors can argue with some justification that they are underpaid. Eleven or more years of collegiate and post-collegiate training set a high bar to professional entry, particularly when they result in $150,000 or more in debt, as often is the case. Once in practice, physicians shoulder an extremely high level of professional responsibility, are highly scrutinized and regulated, and are frequently sued by patients expecting results that cannot reasonably be achieved.
While some might question the value to society of stock brokers, lawyers, or even public relations executives like me, the benefits physicians bring to society are beyond dispute. By delivering, enhancing, and prolonging life, and by easing its passage, physicians provide a service worthy of considerable reward.
Of course, money itself is not the only, or even the primary, sticking point for many doctors—empowerment is. Unlike just about everyone else trying to earn a living, most of you reading this cannot raise yours fees when your cost of doing business rises. Unlike the rest of us, you cannot even submit a bill with any expectation that it will be paid. Perhaps most frustrating of all, you cannot suggest a course of treatment for your patients with the assurance that it will be approved by someone with far less medical training. Little wonder that many doctors feel powerless and marginalized.
The upshot is that a growing number of physicians are looking for a way out, either by retiring, finding non-clinical jobs, limiting access to their practices, working part-time, working as temps or circumventing third parties through direct-to-patient contracting.
Despite prevailing notions, medical practice today often is inequitable to doctors, and many physicians are not as well off as the public may perceive. For every plastic surgeon making millions from elective cosmetic procedures, there are dozens of primary care doctors unable to afford the cost of implementing electronic medical records or even raises for their staffs.
This is not a good prescription for attracting the best and brightest people society has to offer to a profession that eventually affects all of us in a profound way.
These reimbursement woes are one of the drivers of a looming nationwide physician shortage, and payment disparities have already made primary care physicians scarce in many areas.
If you believe physicians are overpaid now, wait until no one wants to be one. That is the point at which we will all be paying a high price, not only with our wallets, but with our health.
Phillip Miller is vice president of communications for Merritt, Hawkins & Associates, a national physician search firm and a division of AMN Healthcare. He can be reached at pmiller@mhagroup.com.
New York hospitals had higher rates of infection in surgical ICUs than any other state in 2007, according to a recent audit by the state Department of Health. Officials say the data found in the study will help hospitals to reduce health risks by identifying risk factors.
As of October 1, a rule issued last year by the Centers for Medicare & Medicaid Services will stop payments to hospitals for hospital-acquired conditions found to be "reasonably preventable." But with a new proposal to add more health conditions to the list, officials with the American Medical Association are raising concerns.
More than $36 million will be paid to health professionals under the Physician Quality Reporting Initiative. The voluntary program, established in 2006, is offering bonus payments to those who reported data on their quality of care between July and December 2007.
A recent study found that patients' medical records don't always reflect errors and other events that may have occurred during their hospital stay. As some are more serious, yet preventable, hospitals should consider adding discussion about adverse events during post-discharge interviews.
The period following a patient's discharge from a hospital to the time the patient re-enters the healthcare system via a physician office visit or other means can be treacherous for the patient. Nearly 12% of patients in a population of more than 15,000 had new or worsening symptoms within two to five days following discharge from the hospital, says a study in the March/April issue of the Journal of Hospital Medicine. If corrective steps are not taken to improve how transition management is handled in hospitals, the risk of errors and near misses in the post-hospital discharge time period is likely to rise.
Void in post-hospitalization patient care
After a patient is discharged, there is a gap of time before he or she re-enters the healthcare system-most often through a visit to a primary care physician or specialist or through a home health visit. This period of unsupervised recovery is fraught with potential dangers. Roughly one in five discharged patients, 21%, required assistance in at least one area that could impact their recovery, according to data from IPC The Hospitalist Company, for the 12 months ending June 2007. This finding parallels industry statistics on the number of patients having issues that could potentially jeopardize their recovery, from forgetting to pick up important prescriptions to having a bad reaction to a medication. Sometimes home health providers do not show up. Patients may have difficulty scheduling outpatient appointments for timely follow-up care. Ultimately, some patients get worse and wind up back in the hospital; starting the cycle over, ratcheting up both suffering and costs.
Using IT to improve the discharge process
Why does this bounceback cycle occur? What can be done to change the outcome? The standard of care in almost every community is to give patients discharge instructions and have them assume responsibility to fulfill the plan. Yet some patients do not receive adequate education about their discharge plans, and many are unable to understand or follow the plan. Family members and caregivers may be of help, or they may add confusion to the process. In the absence of discharge notes and an admission summary, the patient's own primary care physician is often in the dark during a post-hospitalization visit and is not able to act quickly. Additionally, time and money must be spent chasing down the patient's records. Without a defined process to catch problems and correct them, it seems many patients are just discharged into a black hole. And post-hospitalization outcomes measurements are being sucked down with them.
The healthcare industry can, and must, do better. Today, information technology systems can play an important role in improving patient transition management. Shipping companies track packages and provide delivery instructions along the way; yet the healthcare system has not yet found a way to successfully track patients.
At IPC The Hospitalist Company, we have embraced information technology as the critical component of a successful multi-stage patient transition management program. The system is helping our physicians and patients avoid the black hole.
In creating this system, we learned that effective transition management involves communicating with both the patient's primary care physician and with the patient. Not surprisingly, very different types of communication are required for these different audiences.
Enhancing physician-to-physician communication
First, let's look at the physician's point of view. In recent years, many primary care physicians have stopped making hospital rounds. As this change in practice pattern has occurred, communication breakdowns have increased. An ideal model- - and one that we use to prevent such breakdowns - - requires that hospitalists update all involved parties (primary care physician, insurance company, etc.) upon patient admission and within 30 minutes of the patient's discharge. Before we adopted a technology-based system, patients sometimes appeared at their primary care physician's office to find that neither they nor their doctors knew exactly what had happened during their hospital stay. After the system was implemented, that problem was fixed.
Bring patients into the loop
Better communication among physicians, however, is only part of the solution. We also discovered that discharged patients must be involved in a timely manner. Otherwise, they may fail to follow discharge instructions or fail to recognize a trend toward an acute event requiring immediate attention.
Again, we looked to technology to help drive a solution. We configured our system to automatically produce an individualized "smart survey" based on each patient's hospital experience. We then set up a nurse call center to ensure that patients were contacted by phone within 48 to 72 hours after discharge.
In addition to basic satisfaction and general outcome questions, the survey was developed to ask specific questions related to that patient's care as it is generated from notes available in the relational database. For example, if a patient was discharged on warfarin, the survey includes a question about the patient's knowledge of the need for Protime monitoring. For a patient with an order for a visiting nurse, he or she is asked whether the nurse has called or visited. If a patient reports an unexpected outcome, the nurse conducting the phone call is prompted to intervene right away. The case manager documents the intervention, and the entire survey is immediately faxed to the same healthcare partners who received the discharge notes. The loop gets closed, and those care providers who need to act are armed with information.
Continuity of care saves lives
This type of technology is critical to addressing the serious problem of transition management for today's hospitalized patients. It should be considered unacceptable to continue to allow preventable adverse events after hospitalization.
If proven technology systems are implemented on a national scale, post-hospitalization outcomes could be improved, lives could be saved each year, and millions of dollars of costs (including costs that are never reimbursed to hospitals or physicians) could be removed from the system. In the midst of heightened focus on healthcare issues at the national level, policymakers, elected officials and healthcare executives should promote systems that prevent needless suffering and expense.
Adam Singer, MD, is chairman and CEO of North Hollywood, CA–based IPC The Hospitalist Company, Inc.
Proper lifting techniques used to be part of every nurse's training, but as patients get older, heavier, and sicker, the traditional "Lift with your legs, not with your back," just doesn't work anymore. Injuries to both patients and employees are on the rise, and to make sure that they're providing the best healthcare possible, many hospitals are instituting mandatory mechanical lift programs.
"Historically, you were always taught about body mechanics--knees bent, back straight when you lift a box, but patients are not boxes. When you pick a patient up, they're limp, they move, and their weight is not equally distributed," says Mary Godwin, RN, MSN, in this month's issue of HealthLeaders magazine. Godwin is program manager of training and development, employee health and infection control for Alamance Regional Medical Center in Burlington, NC. Alamance developed its Safe Patient Handling and Moving Program more than three years ago. The program teaches caregivers the importance of using mechanical lifts to assist them in moving patients to a chair, a bed, or the restroom--regardless of their size.
At Baptist Medical Center in Jacksonville, FL, using mechanical lifts is mandatory--regardless of the patient's size, says Chris Olinski, RN, MSN, director of employee health at BMC Jacksonville. Baptist's Transferring and Lifting With Care (or TLC) program was developed in response to a rising number of patient and employee injuries and the organization's desire to provide its patients with quality care.
Keeping nurses and other experienced caregivers on the floor is important as the nursing population ages, Olinski says. But if a nurse is injured while moving patients, there's no telling how long he or she will be out of work. TLC was created to prevent not only injuries, but the loss of knowledge among the nursing staff.
"We wanted to look at what we needed to do... to keep that nurse and her experience at the patient bedside," Olinski says. For nurses to have the piece of mind that their employer is looking out for them and working to keep them safe is important to morale, she says.
Making it easier for staff to move patients also helps a healthcare organization combat two conditions listed in CMS' 2008 list of conditions for which it will not reimburse hospitals: pressure ulcers and hospital acquired fractures, dislocations, and other injuries.
"It's the right thing to do for the patient," says Kristin Vondrak, system director of quality for Baptist Health. "Primarily, it promotes good patient care by empowering the direct care providers. (With TLC) we keep our patients safe and our employees in the workforce longer."
We need to look out for the safety of not just our patients but our employees, too. We need to make sure that they have the equipment they need to prevent on-the-job injuries that will leave our hospital departments without their years of valuable job experience. And we need to make sure that employees with aching backs and sore shoulders aren't taking a chance by continuing to lift patients.
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Before Congress voted to override President Bush's veto of HR 6331 this week, there were a lot of public warnings and discussions about physicians dropping Medicare. Every journalist, lobbyist, and legislator seemed to have a touching anecdote or a troubling statistic handy to illustrate the impact of a 10.6% reduction in Medicare payments.
Now that the cut is off the table for the time being, that possibility doesn't go away for many doctors, even though the public attention will.
Physician dissatisfaction with Medicare has been brewing for years, and it isn't always just about money. The administrative and regulatory burdens are often too costly and frustrating to deal with, particularly for primary care physicians in smaller practices. I argued last week that Congressional intervention was a blessing in disguise, because it was just enough to keep the sinking Medicare ship afloat without plugging the holes.
Moving away from Medicare is still in the back of many physicians' minds. But it is easier said than done.
In fact, completely opting out isn't as good of an idea as it might seem, says healthcare lawyer Randi Kopf, RN, MS, JD. Physicians who officially opt out must file a formal affidavit and can't participate for a two-year period. During the opt-out period, neither the physicians nor their patients may submit any claims for payment to any Medicare carrier. If the patient forgets and submits a claim, it could raise a red flag and trigger an audit.
"A lot of practitioners think they can easily opt out," Kopf says. "If they don't do it properly, they're going to be violating regulations. There are too many hazards."
However, physicians can choose nonparticipation, which is similar to essentially becoming an out-of-network provider. Six months before they want to go non-par, physicians must notify CMS in writing that they don't wish to participate in Medicare, and they must also provide adequate written notice to their Medicare-eligible patients.
Non-par physicians still receive limited reimbursement—they cannot charge patients more than the Medicare limiting amount. They also still must file Medicare claims for patients, and the carrier is supposed to send reimbursement directly to the patient. But claims can be filed electronically, and nonparticipation eliminates some of the operational burden.
"[Physicians'] finances may not change actually, but their practice style so radically changes that they can spend more time with the patient," says Kopf.
Choosing nonparticipation is still a difficult decision. Consider these four questions before moving forward:
Are you considering dropping all insurance? If your practice will be accepting other insurance, dropping Medicare shouldn't be an option, Kopf says. If you already have a staffer to handle those claims, then you won't see significant cost savings by selectively dropping Medicare.
Does the compensation you receive for participating allow you to practice medicine comfortably? For most, the answer to this is a resounding "no." It's an important question to consider, because you probably won't see a reimbursement spike after going non-par. However, if you would like to spend more time with patients and end the assembly-line practice of medicine, it may be worth pursuing.
What percentage of your practice has Medicare as their primary insurer? The greater your reliance on Medicare patients, the riskier it is to go non-par. For physicians seeing only a handful of Medicare patients, Kopf recommends nonparticipation or seeing the Medicare eligibles for free. "Some physicians, those who are not proceduralists, are basically seeing them for free anyway. As a non-par, you have the same medical liability, but you don't have all the paperwork headaches."
How many staffers do you having managing and filing insurance claims? This is the key financial question, because any bottom-line improvement will come from eliminating the need for a highly trained staffer to handle billing.
For some physicians, such as surgeons or proceduralists, nonparticipation may be a bad move because it's hard for patients to pay out-of-pocket. Even for primary care doctors, it's a decision that "takes a little courage," Kopf says. Physicians may find themselves a lot braver, however, if Congress hasn't fixed the system when the next cuts roll around in 2010.
Elyas Bakhtiari is a managing editor with HealthLeaders Media. He can be reached at ebakhtiari@healthleadersmedia.com.Note: You can sign up to receive HealthLeaders Media PhysicianLeaders, a free weekly e-newsletter that features the top physician business headlines of the week from leading news sources.
