Leading provider groups used the last day of a public comment period to urge CMS to scale back the proposed rule establishing meaningful use criteria for electronic health records incentive programs.

The Englewood, CO-based Medical Group Management Association asked CMS to formally request a one-year legislative extension of Stage 1 of the incentive program from Congress.

MGMA President/CEO William F. Jessee, MD, said in a 43-page letter to CMS Acting Administrator Charlene Frizzera that a failure to substantially modify the proposal would risk meeting the goals for health information technology adoption under the $21 billion stimulus package.

"The meaningful use requirements must be achievable and verifiable without creating an undue burden on eligible professionals and their administrative staff. This is especially critical in the first years of the incentive program," Jessee said.

AMA Board Member Steven J. Stack, MD, also called the Stage 1 criteria proposed by CMS "too aggressive."

"It could unreasonably punish physicians who undertake great efforts to achieve meaningful use of EHRs— only to be denied incentive payments due to overly complex and unattainable criteria," Stack said in a media release. "We are committed to EHR adoption that streamlines physician practices and helps them continue providing high-quality care to patients, but successful integration of EHRs into patient care takes time."

AMA is recommending that CMS:

• Remove the "all or nothing" approach and require physicians to meet five of the 25 proposed objectives and measures instead of all 25.


• Eliminate the objectives and measures that don't directly apply to EHR adoption, such as checking insurance eligibility electronically.


• Revise the definition of meaningful use for certain hospital-based physicians to broaden eligibility for the federal incentive programs.


• Reduce the number of quality measure reporting requirements and allow physicians to identify only three clinically relevant measures.

"Overall, the proposed reporting criteria require more flexibility," Stack said. "We'd like to see more help for physicians in identifying the data necessary for accurate reporting."

A recent survey found that employers are frustrated that employees aren't taking advantage of their work-based wellness programs to rid themselves of unhealthy habits such as smoking and excess weight.

This frustration is understandable. The primary motive for the wellness movement, however well-intentioned, is to reduce healthcare costs, which are growing at unsustainable rates.

There is nothing wrong with looking at the bottom line, except that your business might fall into that reliably flawed expectation within the personal fitness movement that if you simply spend money, you will get good results.

Years ago, I read an essay which argued that our goal attainment processes are out of order. As best as I can recall with my graying memory, the essayist argued that the normal process of reaching a goal was: "want, work, get." In other words: "If I want to lose weight, I will exercise and eat right, and I will get the results."

Now, in the age of advertising, credit cards, and instant gratification, Americans have skewed the process into: "want, get, work." In other words: "If I want to lose weight, I will get the home gym, buy the $125 running shoes, or join the health club, and then I will lose weight."

Of course, what is left out of the second equation is the actual exercise–the work—that will result in the weight loss. We lace up the running shoes for grocery shopping. We join the health club but interest wanes. We see the guy with the six-pack abs on late-night TV. We see the five-easy-payments plans. We buy the exercise equipment, use it a few times—-or not—and tuck it under a bed. Don't believe me? Ask a fitness trainer how much health club attendance drops off –right about now—when New Year's resolutions get fuzzy. Do an eBay or Craig's List search for "Bowflex," "like new," or "still in box," and count the hits.

The evil twin of the "want, get, work" dynamic is instant gratification—best exemplified by the wonder diets that promise to shed 20 pounds in one week. The diets may work. But, the weight loss is almost always temporary. That is because the people who undertake these dramatic regimens may be prepared for short-term deprivation, but they haven't made the long-term lifestyle adjustments needed to keep the weight off.

I'm sensing that these mischievous twins have wangled their way into the boardroom. The suits in the C-Suite have listened to HR, they bought into the wellness movement as cost-effective, they built the on-site gym, they paid for the weight-loss or smoking cessation classes. So, where are the savings for the next quarterly report?

This is the tricky part. As I said earlier, the wellness movement's primary motivation is saving money. However, any employer, or employee, who embraces the wellness movement has to look at a return on investment that might not materialize in the next few quarters. Wellness is not a penny stock. It's more like a 30-year T-note. This is an evolutionary process.

After all, Americans didn't just wake up one morning and discover they were overweight, or getting older, or addicted to nicotine. These health issues are the result of years, if not decades, of unhealthy choices that people have made. To expect that an employee is going to lose 30 pounds in the next six months because you're paying half of his gym fee is not realistic.

That doesn't mean that we should give up on the wellness movement. The fact is, we are seeing progress in societal wellness. The "obesity epidemic" has flattened—not fattened—over the last 10 years.

Fewer than one in five Americans now smoke—down from more than 42% of the population in 1965. That's taken more than 40 years, and a lot of money, but I don't believe anyone would argue that the effort wasn't worth it—or that more needs to be done.

The employer-sponsored wellness movement is still quite young. As the movement matures, it will become more effective as it finds the right combination of incentives and benefits that will nudge employees to adopt healthier lifestyles. Now is not the time to get discouraged. Now is the time to take the long view.

Depending upon how well they are organized, board meetings can provide vital monthly or quarterly face-to-face time among the decision-makers to keep your physician practice running smoothly.

Or, they can devolve into a cat rodeo; a huge waste of time and energy, where very well educated, very opinionated, highly trained professionals find themselves arguing over the everyday and trivial issues that should be solved on the middle-management level.

At Radiological Associates of Sacramento (RAS), the monthly practice board meeting is a model of efficiency. It is no small feat to get the 64 physician-owners of the practice to sit down for some two to four-and-a-half hours every month to review critical governance issues. But the efficiencies built into the meetings, which might seem effortless to the casual observer, are actually the result of constant streamlining and review, says Fred Gaschen, executive vice president at RAS.

"I'm proud of the way they have organized this," Gaschen says. "I've been here more than 13 years and I inherited a good structure. But I'd like to think that in that time we have streamlined and improved the structure."

RAS has been around since 1917, and Gaschen says the physicians in the practice know enough to let the business people they've hired to run the business, run the business. The business side takes care of the minutia, and helps the physicians organize the subcommittee and board meetings.

"We support the decision-making process by the physicians at the board level through our infrastructure," Gaschen says.

This all seems perfectly logical and simple. Don't waste everybody's time squabbling for hours about lower-level management issues that prolong meetings, force you to skim through more important issues, and leave practice partners irritated by the sense that important issues are not being addressed. But it's surprising how many physician practices run their meetings exactly that way, says Ken Hertz, principal, MGMA HealthCare Consulting Group, based in Monroe, LA.

What's on the agenda?

"I don't think you want to spend a half-hour at a board meeting deciding what kind of chairs you are going to put in the reception area. I don't think you want to spend a half hour at the board meeting or partner meeting deciding whether Dr. Jones' nurse Mary should get a bigger raise than the other nurses, because she has been here longer and, after all, she does three times the work everybody else does," Hertz says.

Instead, he says, the board should focus on governance. "We are talking about strategic issues—mergers, acquisitions, integration, recruitment, strategic decisions to develop a marketing plan," Hertz says. "Sitting at the board meeting is not where you read the copy for the ads and Dr. Jones says 'I don't like the way that paragraph is written.' It is your right to question, but there are certain things you need to entrust to a manager or a subcommittee."

To run an efficient meeting, Gaschen says, what is not on the agenda is almost as important as what is on the agenda.

"Small operational issues are not discussed at the board level. The board is responsible for overseeing corporation setting policy and directions. That is their role," he says. "The day-to-day operations are handled by the respective administrative staff hired in the divisions and each division."

For example, RAS has several subcommittees that meet weekly to vet and prepare issues for the larger board to act upon.

"It is at the divisional level they will look at new offices, new equipment, new services, or new medical ways of doing things, and there will be a lot more debate at the division level and the sub-groupings that happen between the monthly board meetings," Gaschen says.

"So the division will arrive at a consensus within its membership and that division will take it forward to the executive committee for informational purposes and the board of directors for final approval. By the time it gets to the board of directors, it has been vetted in multiple stages along the way. Rarely do we bring something up to the board level and there is a big brouhaha."

Meeting parameters

The agenda, the structure, the frequency, and length of the meeting may vary from practice to practice, depending on what works for the practice, Hertz says, but there are also some fundamental, common sense rules that should apply, regardless of whether you've got two or 200 physicians in your practice.

• "Meetings need to start and end on time," Hertz says. "The people who show up on time shouldn't be penalized for the people who don't. It's disrespectful not to start on time and end on time. The more you don't start on time, the more people say 'why should I show up on time?' and then it becomes a downward spiral."


• Meetings need to have a structured agenda and a facilitator to ensure that the agenda advances. "What we really want is the meeting to move forward. I've sat through many meetings where nobody moves. Somebody introduces a topic and it just meanders. There has to be some leadership," Hertz says. In most physician practices, the president of the board or a managing partner should lead the meeting. "I've seen a lot of practices where the administrator or manager chairs the meeting, but I'm not a big fan of that," Hertz says. "They are an employee. It's your practice. You're the governance. The manager can meet with the chair or the president, review the agenda and the material, point out any landmines or other things they need to be aware of, but, ultimately, a board needs to do the board's work."


• Physicians need time to prepare for the meeting. Hertz says one of the most common complaints he hears from physicians is that they aren't given a chance to plan for the meeting. He recommends publishing agendas as far in advance as possible. "You come to the meeting and somebody gives you a 15-page report and expects you to comment on it. That is not right," Hertz says. "I also hear 'I came to the meeting and all I heard was reports and I left.' Well, then why have a meeting? Put it in writing and e-mail it to me." Hertz says some practices don't issue the agenda because they say their physicians won't bother to read it. "I say 'I don't really care.' The right thing to do is give it to the docs in advance and they read it or they don't. It's their choice, but that is the proper way to do it."


• Don't rehash the same issue in meeting after meeting. "Some practices allow that. Some practices say 'We made the decision. We are moving on.' If it is a major decision that the board is going to make and the board isn't made up of all the partners in the group, it is incumbent on the part of the board to get the shareholders input before the meeting and before the decision is made."

In the end, the board can't allow itself to get bogged down on one issue. Make a decision. It all comes back to leadership.

Connecticut Attorney General Richard Blumenthal said this week that his office has uncovered a potentially anticompetitive practice by health insurance companies that could raise healthcare costs and lower competition.

In a letter to HHS Secretary Kathleen Sebelius, Blumenthal called for an investigation of these practices at the national level.

Blumenthal said his office has been conducting an antitrust investigation of Anthem Blue Cross and Blue Shield of Connecticut, which is owned by WellPoint, Inc., and has found contractual Anthem clauses—commonly referred to as Most Favored Nation clauses—requiring hospitals and other providers to allow Anthem to pay the lowest reimbursement rates in the industry.

Despite apparently having the best reimbursement deals, Blumenthal said Anthem won't pass on its savings to policyholders. Instead, he said the company has sought and received premium increases on Connecticut health insurance consumers, and possibly elsewhere in the country, of at least 13% to 20%.

"Our investigation remains ongoing, but federal officials deserve immediate warning about these practices—potentially having national implications and warranting federal investigation," Blumenthal said in a media release. "Small businesses, individuals—and our entire economy—have a direct and immediate stake in practices that straitjacket hospitals and raise healthcare costs."

"WellPoint and Anthem—among the most powerful players in the health insurance industry—may be exploiting its strength to force hospitals into giving them the best deal in the market. As a result of Anthem's practices, competitors are forced to pay more, hospitals are forced to accept less from Anthem—and consumers are the ones paying," Blumenthal said.

Blumenthal added that less than a year ago, Anthem received approval for premium increases between 13% and 20% on individual health insurance policies in Connecticut, even as the company acknowledged paying at least 39 executives a minimum of $1 million each.

Anthem said its premium hikes were owing to the trouble economy, because "younger, healthier policyholders who lose their job are canceling their health coverage. This means there are fewer policyholders, resulting in those who are left having to pay more."

Anthem issued a statement saying it is working with Blumenthal's office, but the health insurer insisted it has done nothing wrong.

"We have no reason to believe that any provision in our hospital contracts is in violation of applicable law," Anthem said. "When negotiating contracts with hospitals, Anthem makes every effort to obtain fair market reimbursement rates for our customers.

"The increases in premium costs, however, are driven by much more than the increase in hospital rates. An aging population, higher patient utilization, the increase of chronic disease, new high-cost technologies, and cost shifting from Medicare and Medicaid all contribute to rising insurance premiums."