Physicians News » Featured http://www.physiciansnews.com Tue, 07 Feb 2012 16:44:06 +0000 en hourly 1 http://wordpress.org/?v=3.2.1 Help Your Patients Get the Benefits They Deserve http://www.physiciansnews.com/2012/02/01/help-your-patients-get-the-benefits-they-deserve/ http://www.physiciansnews.com/2012/02/01/help-your-patients-get-the-benefits-they-deserve/#comments Wed, 01 Feb 2012 19:07:18 +0000 Physicians News http://www.physiciansnews.com/?p=4583 [/caption] By Eric A. Shore, J.D. and Pia Horton Everyday your patients trust you to care for their health. Many of your patients find themselves unemployed and therefore, uninsured. While some will find work eventually, those with physical and/or mental limitations may not. This is especially true for those approaching retirement age (50-65 years). You can help. Patients who are unable to sustain work due to their health may be eligible for Social Security disability benefits, therefore making them eligible for Medicare or Medicaid. Although treating your patients is obviously your primary concern, taking a few steps to encourage patients to apply and obtain Social Security benefits may be necessary for them to afford the care you provide. Physicians play an instrumental role in helping their patients obtain the Social Security disability benefits they need.  Social Security disability claims are evaluated by determining whether your patient suffers from a severe physical and/or mental impairment that has lasted and/or will last for twelve (12) months, and/or result in your patient's death.  Judges and attorneys review your medical records, looking for your specific documentation of your patient’s physical and mental limitations and how those limitations are caused by your patient's impairments.  To be most helpful, your medical records should also indicate how those limitations prevent or restrict your patient's ability to function on a daily basis. The severity and duration requirements can only be proven by obtaining proper medical evidence, as medical evidence is key to any successful Social Security Disability claim.  Social Security cases are often built and won on the strength of the medical records provided by a client’s treating physician.    Therefore, detailed progress/treatment notes, an accurate accounting of your patient's subjective complaints, referrals to specialists, and referrals for objective testing are necessary to build a winning claim. Your treatment notes are an important part of building the strength of your patient's case.  Consistent treatment should be documented with detailed narratives that include the following: specific dates of treatment, your diagnosis, the nature of your patient’s illness, its etiology, severity, and to what degree the impairment limits your patient’s ability to perform day to day activities, function on a job, and/or maintain full time employment. For example, if your patient has COPD and experiences severe dyspnea, chest pains, wheezing, and fatigue upon minimal exertion, indicate all in your treatment narratives.  Further indicate that medium and heavy exertional level activities are not recommended for your patient, and document specific functional restrictions and/or precautions that your patient should exercise on a daily basis.   Also, note why your patient should not partake in specific exertional activities.  For example, "due to Chronic Obstructive Pulmonary Disease, my patient’s lung volume capacity is severely compromised.  My patient should not lift any weight over ten (10) pounds frequently; never climb ladders; never walk for more than five (5) minutes; avoid vacuuming, dusting, mopping, and standing for more than thirty (30) minutes at a time; avoid all exposure  to dust, chemicals, or other environmental hazards."  Also indicate what adverse effects your patient will experience if he or she partakes in any of the restricted activity Your patient’s subjective complaints are extremely important to record upon every visit to your office.  Often, subjective complaints suggest the true severity of your patient’s impairment and how the impairment limits his or her ability to function.  Subjective complaints of chronic and severe pain should prompt further objective testing, physical therapy, and/or referrals to specialists. The results of objective tests offer concrete evidence that cannot be disputed.  Making timely and accurate referrals for CT scans, MRI’s, and X-rays can strengthen your patient’s case and provide and further confirm your diagnosis.  In addition, timely referrals to specialists and physical therapists document the severity of your patient’s impairment and can significantly increase the chances of winning the claim by indicating your patient’s need for ongoing care and treatment.  With the proper referrals, your patient can build a well documented treatment history, which will in turn bolster your patient’s credibility and increase his or her chances of success.  Moreover, timely objective testing can show permanent impairments, helping to satisfy both the severity requirement and the twelve (12) month duration requirement.  For example, frequently a patient who suffers from severe asthma and/or airway restriction disease is referred for a  Pulmonary Function Testing (PFT).  The results of an initial PFT may only show a mild impairment.  However, over the course of time, your patient's complaints and symptoms may worsen requiring you to refer them for further testing.  Subsequent tests can document how your patient's illness has progressed from tolerable to disabling. Often times, physicians note that their patient is applying for disability benefits, but do not indicate whether they have observed whether their patient is disabled.  Therefore, your observations of how your patient’s impairments affect them should be documented, as well. For example, noting that your patient walks with a limp, experiences frequent falls, has difficulty getting on or off of your examining table, was short of breath walking a short distance, heard voices, could not focus during your exam, could not walk from the waiting room to the treatment room without assistance, winces in pain to your touch, or requires assistive devices to ambulate, can benefit your patient’s claim. When your observations are consistent with your patient's subjective complaints and objective test results, the strength of your patient's claim increases substantially. Moreover, completing simple questionnaires or residual functional capacity (RFC) forms indicating how your patient’s impairments limit their ability to function can be invaluable to your patient’s claim.  Residual Functioning Capacity (RFC) forms and/or Medical Source Statement (MSS) are of great importance to any Social Security disability claim.  The forms help Social Security to evaluate the functional limitations caused by your patient's impairments by giving us insight into how those impairments limit the ability to perform work related activities.  The form consists of a list of physical or mental activities allowing the treating physician to assess their patient's ability to perform work related activities by indicating how the patient’s ability to function is limited by his or her impairment.  More importantly, the form contains sections that allow you to further comment on your patient's limitations in a brief narrative.  In a sense, the form gives you an opportunity to be present at your patients hearing. A supported RFC form completed by you may be the most influential piece of evidence in the case and may actually determine whether your patient will receive the benefits they need.  We know completing forms and copying records for legal matters are not a primary concern. However, because your assistance can be the deciding factor in whether your patient will obtain Medicare/Medicaid and the cash benefits needed to afford transportation to your office, helping patients with their Social Security disability and SSI cases is different. The Social Security Administration must consider all medical evidence of record in your patient's claim including your records and opinions, and give great weight to all evidence submitted by you, the treating physician.  Therefore, your observations, recommendations, referrals, and treatment plans are crucial in assessing your patient’s case and achieving the favorable outcome your patient needs and deserves. ### The Law Offices of Eric A. Shore, P.C. (www.1800cantwork.com) focuses on matters of Social Security Disability and SSI benefits.  They can be reached at 215.627.9999.    ]]> http://www.physiciansnews.com/2012/02/01/help-your-patients-get-the-benefits-they-deserve/feed/ 1 Practical Implications of Telemedicine Credentialing http://www.physiciansnews.com/2012/01/30/practical-implications-of-telemedicine-credentialing/ http://www.physiciansnews.com/2012/01/30/practical-implications-of-telemedicine-credentialing/#comments Mon, 30 Jan 2012 20:03:46 +0000 Physicians News http://www.physiciansnews.com/?p=4569 By Lucia Francesca Bruno, J.D., LL.M., M.B.A. For the past century, information technology has reinvented the familiar and revolutionized the art of medicine.  As health care professionals struggle to keep pace with an ever-changing and consolidating industry, traditional forms of health care have succumbed to modern technology and fiscal constraints.  No longer are patients and providers afforded the luxury of being in the same place at the same time.  Recent developments in patient-service delivery systems have transformed the doctor/patient relationship; paving the way for advances in telemedicine and the credentialing and privileging of telemedicine practitioners.  Inside Look into Telemedicine The Centers for Medicare and Medicaid (“CMS”) defines telemedicine as “the provision of clinical services to patients from a distance via electronic communications.”[1] Although telemedicine is not considered a medical specialty, products and services unique to this practice of medicine often require a costly investment in information technology and the delivery of clinical care by health care providers. Telemedicine seeks to improve a patient’s health by permitting two-way, interactive, communication between the patient and the physician, at a distant-site, for purposes of assessment, diagnosis, and intervention.  Examples of telemedicine include, but are not limited, to the following:  videoconferencing; transmission of still images, and remote monitoring of vital signs. A Past Marred by Obstacles Historically, smaller hospitals and Critical Access Hospitals (“CAHs”) desiring to take advantage of this cost-effective form of clinical care were hampered by duplicative and burdensome Conditions of Participation (“CoPs”) and redundant regulations.   In particular, the credentialing process of obtaining and reviewing practitioner data such as licensure, training, certifications, insurance, and National Practitioner Data Bank queries created a financial burden many hospitals simply could not afford.   Furthermore, many lacked the clinical expertise within their medical staff to evaluate and grant privileges to physicians providing telemedicine services. In a notorious policy brief issued by the National Rural Health Association (“NRHA”) in 2010, providers maintained that “the current telehealth credentialing process was more than an annoyance; it was a deterrent for providers and hospitals, and a barrier to expanding health care access.”[2]  NRHA urged CMS to “adopt a policy that allowed telemedicine providers to receive deemed status (as having met Medicare/Medicaid certification requirements) and permit health care facilities receiving telehealth services to perform credentialing by proxy (delegated credentialing).”[3]  NRHA surmised that “if a provider was already credentialed at a Medicare-participating facility, that credential would be sufficient to provide telemedicine services at another facility; while, the privileging process would remain the responsibility of the originating health care facility.”[4] A Future Swayed by Reason Acknowledging the need for transformational change, on May 5, 2011, CMS introduced the final rule which superseded prior Joint Commission privileging recommendations, and considerably streamlined the credentialing and privileging process for physicians providing telemedicine services. [5] The final rule, effective July 5, 2011, made Federal requirements more flexible and encouraged innovative approaches to the delivery of patient-services; thereby, allowing patients to receive medically necessary interventions in a timelier manner.[6]   In addition to taking a more lenient approach to CoPs, CMS expanded the platform of telemedicine by defining key terms and requiring a written agreement between the "patient-site" and the "distant-site."   The written agreement, subject to disclosure to CMS, must include specific elements and evidence the telemedicine practitioner’s privileges at the “distant-site.” Key Terms Defined by CMS “Telemedicine” is defined as “the provision of clinical services to hospital or CAH patients by practitioners from a distance via electronic communications, either simultaneously or non-simultaneously.”[7] “Simultaneous” telemedicine services are performed in real-time, similar to the actions of an on-site practitioner when called in by an attending physician to see a patient, e.g., teleICU services. [8] “Non-simultaneous” services are clinical services provided to the patient upon a formal request from the patient’s attending physician or practitioner; such services may involve after-the-fact interpretation of diagnostic tests and do not necessarily require the telemedicine practitioner to directly assess the patient in real-time, e.g., teleradiology services.[9] “Distant-site” the location at which the physician or other licensed practitioner delivering the service is located at the time the service is provided via telecommunications.  A “distant-site” is either a Medicare-participating hospital or telemedicine entity (non-Medicare participating hospital) that provides contracted telemedicine services in a manner that enables the hospital or CAH using telemedicine services to meet all applicable CoPs; particularly, those related to the credentialing and privileging of telemedicine practitioners. [10] Written Agreement Required:  Distant-Site Hospital When the distant-site is a Medicare-certified hospital, the final rule requires that the hospital or CAH have a written agreement that expressly states that it is the responsibility of the distant-site hospital to meet the credentialing requirements of 42 C.F.R. 482.12(a)(1)-(a)(7) for hospitals or 42 C.F.R. 485.616(c)(i)-(c)(vii) for CAHs.  In addition, the written agreement must contain the following: (i) the distant-site hospital is a Medicare-participating hospital; (ii) the distant-site practitioner is privileged at the distant-site hospital as evidenced by a current list of the practitioner’s privileges provided by the distant-site hospital; (iii) the practitioner holds a license issued and/or recognized by the state in which the hospital or CAH whose patients receive telemedicine services is located; and (iv) the hospital that credentials and privileges the distant-site practitioner disclose the practitioner’s performance information, e.g., adverse events, complaints, and internal reviews. Written Agreement Required:  Distant-Site Telemedicine Entity To rely on the credentialing and privileging decisions by a distant-site telemedicine entity, the distant-site must affirm, in writing, that the telemedicine entity is a contactor of services to the hospital and furnishes contracted services in a manner that permits the hospital to comply with all applicable CoPs, 42 C.F.R. 482.12(a)(1)-(a)(7) for hospitals or 42 C.F.R. 485.616(c)(i)-(c)(vii) for CAHs.  In addition, the written agreement must contain the following: (i) the distant site’s credentialing and privileging process at least meet the standards in 42 C.F.R. 482.12(a)(1)-(a)(7) and 42 C.F.R. 482.22(a)(1)-(a)(2) when the originating-site is a hospital or 42 C.F.R. 485.616(c)(1)(i)-(c)(1)(vii) when the originating-site is a CAH; (ii) the distant-site practitioner has the experience and expertise as represented by the distant-site telemedicine entity; (iii) the practitioner holds a license issued and/or recognized by the state in which the hospital or CAH is located; and (iv) the hospital or CAH has evidence of an internal review of the distant-site practitioner’s performance of privileges to be exercised at the hospital or CAH; conversely, the hospital or CAH  must send the distant-site entity performance information for use in the entity’s periodic appraisal of the distant-site practitioner. Effect on State Licensure Despite the sweeping reform brought about by the final rule, CMS cautioned that all state-based physician licensure requirements will remain unchanged. Recognizing the fact that “licensure laws and regulations have traditionally been, and continue to be, the provenance of individual States, the final rule does not pre-empt State authority.”[11] Although states remain split on the issue of telemedicine, many states espouse that their existing laws adequately reflect their position on the licensure of telemedicine practitioners.  Other states, however, affirm that a full and unrestricted license is necessary to practice telemedicine, and have reinforced that stance in law or policy.[12] In an effort to address growing concerns amongst medical professionals, the American Medical Association (“AMA”) reaffirmed its policy to support state-based licensure for physicians and oppose national licensure approaches to telemedicine. In its annual assessment of physician licensure, the AMA declared that “telemedicine in particular has crystallized the tension between the states’ role in protecting patients from incompetent physicians and protecting in-state physicians from out-of-state competition, and the desirability of ensuring patients’ access to the highest quality medical advice and treatment possible, wherever located.” [13] Despite tension between the states’ power to regulate health care professionals and the prohibition against restraint on interstate commerce, the practice of telemedicine has yet to be addressed by the courts.  Only time will tell if the final rule is sufficient to spur litigation in this cutting-edge practice of medicine. Informed Consent Considerations Despite comments to CMS encouraging patient informed consent be obtained before the use of telemedicine services by a hospital or CAH, CMS affirmed that under the final rule “there is no difference between distant-site practitioners and in-house or on-site practitioners with respect to informed consent.”[14]  CMS reiterated that “as long as the telemedicine practitioner is performing his or her duties within the privileges granted by the hospital or CAH, in accordance to a policy that requires informed consent, then consent must be obtained regardless of whether treatment is furnished by telemedicine or not.”[15]  For providers, this insightful decision alleviated one more instance of costly red tape.  Medical Staff Bylaws and Standard Operating Procedures In order to ensure full compliance and avoid unnecessary complications, providers are encouraged to amend medical staff bylaws and revise policies and procedures related to credentialing and privileging.  In particular, medical staff bylaws should contain current definitions relevant to telemedicine and an accurate description of the information-sharing process.  Medical staff bylaws should also reflect administrative changes to the provider’s Credentials Committee and Medical Executive Committee, especially as it pertains to clinical services provided by telemedicine. Furthermore, medical staff policies and procedures should be amended to account for changes in clinical protocols, insurance coverage, billing and reimbursement, and HIPAA compliance.   As a precautionary measure, any medical staff policies that require the “physical presence” of a physician should be reevaluated to account for the delivery of patient services by electronic communications. Finally, under the final rule, hospitals and CAHs that take advantage of privileging by proxy must disclose privileged peer review information to the distant-site.  Therefore, it is advisable that hospitals and CAHs carefully assess state-specific peer review guidelines and include language in the written agreement that ensures ongoing protection of peer review information. Conclusion There is no doubt that sweeping changes in the credentialing and privileging process has paved the way for greater advances in telemedicine services.   Dale Alverson, M.D., past president of the American Telemedicine Association surmised that “the final rule will truly help patients receive the care they need, no matter where they live or where their doctor is located.”[16] By eliminating the overly burdensome credentialing and privileging rules in Medicare, Dr. Alverson concluded that “CMS has shown growing support of telemedicine.” [17] Despite the obvious benefits to patients, the long-term ramifications of the final rule on providers are yet, unknown.  Hospitals and CAHs using telemedicine services of distant-site practitioners are, therefore, encouraged to implement adequate policies and procedures to protect their interests and those of their patients. ### Lucia Francesca Bruno, J.D., LL.M., M.B.A., is Principal Shareholder of Physicians’ Legal Group, LLC (www.physicianslegalgroup.com). She can be reached at Lbruno@physicianslegalgroup.com.  

[1] Medicare and Medicaid Programs: Changes Affecting Hospitals and Critical Access Hospital Conditions of Participation: Telemedicine Credentialing and Privileging, 76 Fed. Reg. 25, 551 (May 5, 2011).
[2] Lewis, Pam, Mandy Bell, BA,  Deanna Larson, RN, BSN, and  Jay Weems, MBA:  “Telehealth Provider Credentialing” National Rural Health Association Policy Brief (2010): 1-4.
[3] Lewis, Bell, Larson, Weems, Telehealth Provider Credentialing, 1.
[4] Id. at 1
[5]  Medicare and Medicaid Programs: Changes Affecting Hospitals and Critical Access Hospital Conditions of Participation: Telemedicine   Credentialing and Privileging, 76 Fed. Reg. 25,550, 25,551 (May 5, 2011).
[6] 76 Fed. Reg.  25,551.
[7] Id. at 551.
[8] Id.
[9] Id.
[10] Section 1834(m)(4)(A) of the Social Security Act
[11] 76 Fed. Reg.  25,557.
[12] Office for the Advancement of Telemedicine, “Telemedicine Licensure Report” (2003).
[13] American Medical Association, “Physician Licensure: An Update of Trends” American Medical Association, 2012. Web. 15 January 2012 http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/young-physicians-section/advocacy-resources/physician-licensure-an-update-trends.page.
[14] 76 Fed. Reg.  25,555.
[15] Id. at 255.
[16] http://learntelehealth.org/blog/post/final-ruling-on-credentialing-privileging-of-telehealth-providers/
[17] Id.
]]> http://www.physiciansnews.com/2012/01/30/practical-implications-of-telemedicine-credentialing/feed/ 0 Health Care Reform Debate: More Thought and Less Volume, Please http://www.physiciansnews.com/2012/01/26/health-care-reform-debate-more-thought-and-less-volume-please/ http://www.physiciansnews.com/2012/01/26/health-care-reform-debate-more-thought-and-less-volume-please/#comments Thu, 26 Jan 2012 15:58:22 +0000 Physicians News http://www.physiciansnews.com/?p=4556 By Erika Stewart Health care reform will make huge changes in the way insurance companies do business, but most of that will not go into effect right away. Provisions that will help most Americans in 2012 affect policies that were purchased after March 13, 2010. Under the new laws, health insurance companies cannot:
  • Refuse to cover children under age 19 who have a pre-existing condition
  • Impose a lifetime limit
  • Cancel a policy unless they can prove fraudulent information was given
  • Fail to provide an appeal process for denied claims
New insurance policies must now include reasonable preventive services that carry no copayment or deductible. This includes usual vaccinations, cancer screenings, well-child office visits, blood pressure checks, and tests for such chronic conditions as diabetes and high cholesterol. Children without insurance who have not reached the age of 26 can now be carried on their parents' insurance, even if they are married and no longer live with their parents. Newer health plans must allow the patient to choose a primary care physician and cannot require a referral for an OB/GYN service. The law also prohibits companies from requiring patients to go to a particular emergency room or get prior authorization for emergency care. Effects on Physicians While all this is good news for American families, what about the effect on doctors? Why was the bill endorsed by both the American Medical Association and the American Hospital Association? Primary care physicians will receive more pay from government-sponsored insurance such as Medicare for encouraging patients to take advantage of preventive and outpatient services likely to lower the overall cost of care for individuals. They will also receive incentives for providing coordinated care, and for using electronic health records so that patients are better understood. Hospitals will benefit from reducing the number of charity cases without any payment. By 2014 Americans will receive subsidies to help those with lower income afford medical insurance. Starting in 2014, Medicaid will cover most people who have less than 133 percent of poverty level income. This is projected to bring an additional 16 million people into that system. The impact on states will vary, depending on how generous the Medicaid program is there. The Federal government will cover the cost until 2020 but will then ask states to shoulder more of the burden. With many politicians eyeing cuts to Medicaid in order to bring the budget under control, the poorest of American citizens may be in jeopardy of losing some of their medical care. President Obama has promised to cut 0 billion. House Republicans, led by Paul Ryan, are pushing to change Medicaid to a block grant program and repeal the expansion of coverage. Sustainable Growth Rate (SGR) Another interesting aspect of our health care law is Medicare’s Sustainable Growth Rate (SGR). SGR is defined as the fastest rate at which an organization can grow without collapsing. This figure is used to adjust the Medicare fee schedule so that the fund does not become depleted. If expenditures exceed the SGR, the fee schedule is adjusted downward. However, the formula used does not take into account the increasing volume and complexity of care. A true reflection of program costs must take these factors into consideration. Some critics have complained that the health care reform law does not address this issue. That was not the focus of the bill, which deals mainly with issues of insurance coverage. As the debate about health care reform continues, doctors have weighed in both in favor of the law and concerned about its implications. On her blog “Barking Doc,” Maggie Kozel MD presents her perspective. She says, among other astute comments, that the discussion needs to focus on stewardship. As citizens of this wealthy nation, what is our responsibility? Dr. Kozel is author of “The Color of the Atmosphere: One Doctor’s Journey In and Out of Medicine.” After 10 year’s of practice in Navy medicine, Kozel entered private practice where she was confronted with the inequities of the current system and what that means in terms of patient care. Speaking of the relationship between doctor and patient, she writes, “conversation between doctor and patient is the most undervalued commodity in our health insurance system.” Whether the new law will survive attacks by conservatives, and how well it will address the needed changes in our health care system, remain to be seen. Thoughtful debate on the serious issues involved instead of bickering backed by special interests would help both Congress and the President focus on positive change. As Dr. Kozel writes, what is needed is more thought and less volume.                  ]]> http://www.physiciansnews.com/2012/01/26/health-care-reform-debate-more-thought-and-less-volume-please/feed/ 2 Camden Coalition’s Model for High Needs Patients http://www.physiciansnews.com/2012/01/09/camden-coalition%e2%80%99s-model-for-high-needs-patients/ http://www.physiciansnews.com/2012/01/09/camden-coalition%e2%80%99s-model-for-high-needs-patients/#comments Mon, 09 Jan 2012 15:33:37 +0000 Physicians News http://www.physiciansnews.com/?p=4529 By Jen Abraczinskas and Jeffrey Brenner, MD [caption id="attachment_4531" align="alignleft" width="100" caption="Jen Abraczinskas"][/caption] There is a lot of buzz about reducing hospital readmissions.  But what does a readmission look like?  And what will it take to provide the care needed to avoid readmissions? We arrived at the ICU to find our patient sedated and intubated. Yet only 10 days earlier Mrs. P was strong enough to navigate the halls in her wheel chair, had her diabetes and COPD under control and was taking her medications for bipolar disorder. Mrs. P was discharged with an abundance of home health services – nursing, physical therapy, occupational therapy, home health aid.  How had her condition declined so quickly?  We visited her on day three post-discharge.  Mrs. P was in her living room hospital bed covered in her own body fluids unable to turn herself.  We helped her husband clean her, dress her, and move her into a position where her lungs had a chance to fully expand.  We also checked her blood sugar – slightly over 250.  The rehab center had discharged her with sliding scale insulin and believed that her elderly husband knew how to administer it.  However, when we asked him to try, he only pulled up air into the syringe.  He was not strong enough or organized enough to take care of Mrs. P’s incredibly demanding health needs which required over 10 medications, multiple monthly doctors visits, special transportation, and help with daily living activities.  A 4-day lag in her home health agency opening her case was enough time for Mrs. P’s health status to go from good to seriously troubled. [caption id="attachment_4532" align="alignleft" width="96" caption="Jeffrey Brenner"][/caption] Mrs. P’s experience wasn’t a new one.  The ICU stay was her third admission to the hospital in the last three months.  Initially she had been hospitalized for a COPD exacerbation, sent to rehab, discharged home for several hours before a decline that required another hospital admission and then she repeated this cycle. She was frustrated. Her family was frustrated. And we were frustrated as we watched her careen between the best healthcare Camden has to offer and near neglect of her health needs.  The reasons for the cycle are complex with her greatest complication being our fragmented health system.  During her hospital and rehab stays her health improved because she was receiving daily assistance with her complicated medication regime. Following discharge her inability to use her glucometer, administer insulin, and understand her medications left her vulnerable to rapid health decline.  Since her admissions began, she had been disconnected from primary care and getting her into a new primary care doctor would take weeks.  As her husband battled his own health problems, she needed more assistance at home but did not qualify because her Medicaid application is only just started. Mrs. P’s suffering is also costly. During the last three months, Medicare paid over ,000 for Mrs. P’s 3 admissions, including 2 ICU stays, and 11 weeks of rehab.  Preventing her third readmission alone would have saved Medicare ,482.  Then there is the cost to Mrs. P and her family.  She kept losing the good health she would gain in rehab.  Her husband felt guilty and embarrassed that he could not provide the expert care his wife needed to stop cycling in and out of the hospital.   Sadly, Mrs. P. is not alone in her struggles to stay healthy and out of the hospital.  Everyday in the United States, 10,000 more people turn 65 and many will suffer with multiple chronic illnesses, trouble with transportation, and questions regarding what level of care they truly need.  This population will bill Medicare with its expenses and overburden families with its home health needs. To break the hospitalization cycle and to curb healthcare spending, the Camden Coalition of Healthcare Providers has developed an innovative care management model for high needs / high costs patients in Camden NJ.  The Care Management Team relies on home visits with patients to coordinate doctors’ appointments, transportation, and social services.  The Team provides holistic medical care as well as root cause analysis and solutions to the often intertwined issue of poverty and disease that plague its patients. At any given time the Team sees approximately 35-40 patients. We are often asked why we work so intensely on a hand-full of patients.  From analyzing data gathered from three hospitals in Camden, we found that 1 percent of patients account for 30 percent of costs.  If we focus on the heaviest utilizers of health care, connect them into primary care, and address their needs outside of hospitals, we can begin to bend the cost curve.  The numbers are convincing and inform our overarching mission. But every day we also see the faces of patients needing assistance.  It is our patients’ confrontation with or neglect from our fragmented, difficult to navigate healthcare system that fuels the change we are trying to make. The Care Management Team has seen great success with many patients.  For Mrs. P., we ensured home health arrived soon after her discharge from this ICU stay and continued to communicate with them.  We connected her to a new primary care doctor and arranged transportation to her appointments. We involved her family in a discussion about long term goals and are facilitating her entry into an adult day program.  For other patients, we’ve supported them to achieve permanent housing, affordable medications, and primary and specialty care appointments with doctors who they trust.  Yet, we realize that time-intensive care management often falls into the laps of ill-equipped, overburdened primary care providers, hospital residents or insurance companies.  The Coalition is working to supply providers with tools to reduce the time and cost associated with great care coordination.  The Coalition has developed the Camden Health Information Exchange (HIE) to coordinate the hospital discharge summaries, lab data, and radiology reports for Camden residents.  The Camden HIE allows providers to have up-to-date information on their patients’ conditions and eliminates the need to order repeat tests.  We also are positioning Care Coordination Teams in Camden primary care offices.  The Teams will focus on patients with diabetes or high health care utilization for whom extra care coordination support is needed. As we look to the future, working in a more coordinated fashion is the only way that the needs of our growing, aging population will be met in the United States.  In Camden, we are testing models to improve health care and social services navigation, reduce unnecessary utilization, and equip providers with health information and coordination teams.  If we can support patients in their efforts to attain good health, we will decrease costs and be able to provide more and higher quality services for all. ### The Camden Coalition of Healthcare Providers (www.camdenhealth.org) was created with the overarching mission to improve the health status of all Camden, NJ residents, by increasing the capacity, quality, and access of care in the city.   Jen Abraczinskas is a third year medical student at the University of Pennsylvania and is spending a year with the Coalition as an Americorp volunteer.  Jen is a health coach with the Coalition's high utilizer project. Jeffrey Brenner, MD, is Director, Institute for Urban Health at Cooper University Hospital and Executive Director, Camden Coalition of Healthcare Providers. Naomi Wyatt, the Coalition's Director of Legal and Governmental Affairs, contributed to this article.]]> http://www.physiciansnews.com/2012/01/09/camden-coalition%e2%80%99s-model-for-high-needs-patients/feed/ 1 A Challenging Road Ahead for America’s Physicians http://www.physiciansnews.com/2012/01/05/a-challenging-road-ahead-for-america%e2%80%99s-physicians/ http://www.physiciansnews.com/2012/01/05/a-challenging-road-ahead-for-america%e2%80%99s-physicians/#comments Thu, 05 Jan 2012 15:20:33 +0000 Physicians News http://www.physiciansnews.com/?p=4508 By  Louis J. Goodman and Timothy B. Norbeck  This year promises to be a watershed year for healthcare in general, and for patients and physicians, in particular.  No matter how the U.S. Supreme Court determines the constitutionality of the Patient Protection and Affordable Care Act (PPACA), 2012 will be a crucial turning point in the delivery of healthcare. [caption id="attachment_4511" align="alignleft" width="150" caption="Louis J. Goodman, Ph.D."][/caption] During the Congressional passage of the PPACA, White House advisors acknowledged that the economic forces in the legislation would accelerate physician employment by hospitals and larger physician groups.  As mentioned in the “Roadmap for Physicians to Health Care Reform,” the “private” part of private practice for physicians is disappearing.  Currently, more than 80 percent of visits to physician offices have been to practices with five or fewer physicians.  That will change drastically as more physicians feel pressure to move into larger groups or become employed by hospital systems.  Through October of 2011, there have been 71 hospital mergers. All of this will change the face of the delivery aspect of health care, but a question remains: will it be for the better or worse? Expert opinion is almost universal that there is a present shortage of physicians, especially those in primary care and those practicing in rural areas.  This is a workforce problem that must be addressed now, but it seems to be lost in the debate over the PPACA.  The Physicians Foundation recognizes the shortage problem and recently awarded a large grant to The Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill to develop a dynamic web-based projection model that can be continually updated to track ongoing physician workforce needs across the country.  Information gleaned from the UNC research will further enhance efforts to identify where physicians are most needed to support patients in a growing healthcare system.  Thirty-six percent of practicing physicians are over age 55 and may retire by 2020.  According to Physician Foundation surveys conducted by Merritt Hawkins in 2008 and 2010, fewer physicians are seeing Medicare patients or taking on new Medicare patients.  With 10,000 baby boomers becoming eligible for Medicare every single day, the survey results do not bode well for access to care for Medicare patients. [caption id="attachment_4512" align="alignleft" width="150" caption="Timothy B. Norbeck"][/caption] Why do we have fewer physicians seeing Medicare patients at the very time that we need more of them?  First of all, the Sustainable Growth Rate (SGR) used to pay physicians under Medicare, singles out physicians for financial punishment in the form of payment reductions when volume of service increases.  With an aging population and increasing numbers of chronically ill elderly people, of course the volume of services continues to rise.  However, unless Congress steps in and acts promptly, Medicare physician payments are scheduled for an average reduction of 27.4 percent effective January 1, 2012.  The Physicians Foundation joins all other medical associations and the AARP in warning of the dire consequences on patients’ access to care should this massive and unwarranted reduction go through.  The fatally flawed SGR must be fixed and the aforementioned 27.4 percent scheduled reduction must be stopped. Much has been said about the PPACA, some good and some bad.  We would like to address the legislation from a physician’s point of view.  Physicians are extremely happy to have the American public insured and are delighted to have an end to the discrimination against their patients with pre-existing conditions. They also applaud the new focus on preventive care which should help lead to a healthier public.  As for the downside to the legislation, there was no SGR fix and no tort reform.  The PPACA also assumes a planned 30 percent reduction in physician fees scheduled under the SGR over the next three years.  Furthermore, and this is something that is largely overlooked when discussing the legislation, any physician’s office which mistakenly and by mere accident improperly bills too much for a Medicare visit, is subject to potential liability under federal fraud and abuse statutes. Before the PPACA, intent to commit fraud was necessary for a charge of fraud to be made, but now even an innocent error can result in prosecution.  Finally, and also overlooked by many, is the “translation” fee which must be paid by the treating physician.  If a physician treats a patient who doesn’t speak English and requires a translator, the physician is responsible for the translation fee.  In other words, the translator’s bill would probably exceed the physician’s reimbursement for the office visit! These issues and other pressures on physicians help explain some of the survey results from the 2010 Physicians Foundation Health Reform Research Study, and the numbers only become bleaker when comparing the results from our 2008 survey.  Only one-quarter of physicians surveyed said they plan to continue practicing as they are; while half reported that they would adopt a style of practice different from the traditional full-time independent private practice model.  Hence, the “private” in private practice is going, going, gone! Clearly, increasing administrative burdens attributable to the PPACA requirements plus insurance, red tape and costly regulatory measures are having a likely negative effect on patient care.  Sixty-three percent of physicians surveyed claimed that non-clinical paperwork has caused them to spend less time with their patients and 94 percent said that the time they devote to non-clinical paperwork has increased over the past three years.  Ask any physician what he or she enjoys the most about practicing medicine and the response will be: “seeing, helping and interacting with my patients.” The increasing amount of regulations and paperwork are becoming a more formidable barrier to the joy of practicing medicine.  Add to that the declining reimbursements and difficulty in sustaining one’s practice, the constant threat of liability, decreased time with patients and low or no bargaining power with insurers, it is not surprising to note that general physician morale is low and getting lower. A recent Robert Wood Johnson Foundation survey of physicians indicated that four out of five physicians agreed that unmet social needs are connected to declining health for many Americans. By the same ratio, they also agreed that addressing patients’ social needs are just as important as addressing their medical conditions.  An innovative Boston, Massachusetts organization called Health Leads interviewed local physicians about their needs in providing patient care.  Many expressed frustration that they could not help their poor patients beyond simply providing medical care – with housing, nutrition (food) or other resources that could improve their health.  Not only have these important issues been excluded from the health reform debate, they are largely ignored by policymakers. With a substantial grant from The Physicians Foundation, Health Leads has been able to expand their efforts to train college student volunteers in five cities to “assist” physicians to “prescribe” food, housing and fuel assistance, or other resources for their patients – just as they do medication.  Patients then take those “prescriptions” to the Health Leads Family Help Desks located in clinic waiting rooms, where the volunteers “fill” them by connecting patients with those resources.  Most of the student volunteers (64 percent of who are pre-med students) end up choosing to go into primary care – another plus! Generally exacerbating the overall workforce problem is the plight of medical students now coming into practice.  Graduates, on average, carry a debt of 6,000 and payments of up to ,000 a month!  According to the American Association of Medical Colleges (AAMC), each member of the graduating medical school class of 2033 will face a 0,000 debt! So what can be done to help physicians sustain their practices and have more time with their patients?  An obvious place to start would be to fix the unfair SGR – and promptly!  This Congressional and government inability to solve this problem reminds us of the late economist Milton Friedman’s observation on the inefficacy of government: If you put the government in charge of the Sahara Desert, he said, in five years there will be a shortage of sand.  And so it is with the growing shortage of physicians.  Congress should relieve physicians of onerous and time-consuming regulations and insurance red tape – which do not help patient care and only add to the cost of that care.  It should create more incentives for physicians to go into rural areas and find additional ways for medical students to pay off their medical school loans.  Build more medical schools and increase the number of the 25,000 residents and fellows completing their training every year. Of course, the big question is: Where do you find the money to do all this?  Throughout America’s history, that question has been asked many times.  The obvious answer: If you have the will you can find the wallet.  America always has, if the issue is considered important enough.  It won’t be easy but healthcare delivery and its workforce are being challenged in a major way today, and it will only worsen tomorrow without Congress stepping up and addressing it.  As noted in Shakespeare’s Henry VI: “Delays have dangerous ends.” ### Louis J. Goodman, PhD, is President and Timothy B. Norbeck is CEO of The Physicians Foundation, which is a nonprofit 501(c)(3) organization that seeks to advance the work of practicing physicians and to improve the quality of healthcare for all Americans. It pursues its mission through a variety of activities including grantmaking, research and policy impact studies. Since 2005, The Foundation has awarded numerous multi-year grants totaling more than million.  In addition, The Foundation focuses on the following core areas: health system reform, health information technology, physician leadership, workforce needs and pilot projects.  As the health system in America continues to evolve, The Physicians Foundation is steadfast in its determination to foster the physician / patient relationship and assist physicians in sustaining their medical practices during this evolution. For more information, visit www.physiciansfoundation.org.  ]]> http://www.physiciansnews.com/2012/01/05/a-challenging-road-ahead-for-america%e2%80%99s-physicians/feed/ 6 Physician Mind Shift: The Emergency Department in an ACO World http://www.physiciansnews.com/2012/01/04/physician-mind-shift-the-emergency-department-in-an-aco-world/ http://www.physiciansnews.com/2012/01/04/physician-mind-shift-the-emergency-department-in-an-aco-world/#comments Wed, 04 Jan 2012 20:51:50 +0000 Physicians News http://www.physiciansnews.com/?p=4519 By Mark Crockett, MD In the era of accountable care, you’ll notice that many hospitals and health systems are already driving towards more collaborative workflow. The integrated delivery network (IDN) is changing significantly, and for the better. But in high-acuity care areas, like the emergency department (ED), the challenge of treating patients more holistically in what is already a fast-paced environment is concerning for physicians evaluating the pay-for-performance model. In today’s ED, patients may enter with a chronic condition that could be better managed by a primary care physician (PCP), but because ED physicians are incented to treat sick people in a fee-for-service model, they continue to take these patients on instead of referring them outside the ED walls. If instead both ED and primary care physicians operate as part of a team of care givers that are incented to ensure patients stay healthy and avoid hospital admissions and readmissions, they are headed in the same direction in terms of focusing on better patient outcomes vs. reimbursement dollars. ED physicians used to be among the few physicians employed by the hospital, but that’s changing dramatically as IDNs snap up physician groups. The larger group working together will help make sure the ball isn’t dropped anywhere throughout the spectrum of care. If a patient with a laceration comes into the ED with diabetes, and that ED doc doesn’t think to check blood sugar – because that’s more of a PCP issue – that oversight will be visible in an ACO environment and the physician might be under the microscope in terms of the role played in ensuring quality outcomes. Part of this movement requires implementing integrated technology solutions that provide greater visibility into the types of care needed in your community, allowing the health system to build care facilities that are catered to the population it serves, ultimately enabling the sustainable health community. But the real lynchpin for success is the collaboration between people, not just IT systems. This means choosing metrics to support each constituency that has a stake in the game – providers, payers, physicians and patients – so that they buy into the new strategy and are empowered to make changes that support lower costs, increased efficiencies and higher quality care. It takes strong leadership demanding teamwork across clinical, administrative and even third-party vendors, along with a shared passion for making sure patients are cared for in the best possible way to make this happen. ### Mark Crockett, MD, is chief medical officer for Accountable Care Solutions at OptumInsight. He also practices emergency medicine at Advocate Good Samaritan Hospital in Downer’s Grove, Ill. He maintains a solid understanding of the day-to-day workings of an emergency department and the need for automating the documentation process of this intense environment.]]> http://www.physiciansnews.com/2012/01/04/physician-mind-shift-the-emergency-department-in-an-aco-world/feed/ 0 Attract Patients & Keep Them (Healthy) with Social Media http://www.physiciansnews.com/2011/12/23/attract-patients-keep-them-healthy-with-social-media/ http://www.physiciansnews.com/2011/12/23/attract-patients-keep-them-healthy-with-social-media/#comments Fri, 23 Dec 2011 15:18:46 +0000 Physicians News http://www.physiciansnews.com/?p=4504 By Katie Matlack Over on the Software Advice blog, we discussed ways doctors can use social media for a variety of purposes. A recent study reported over half of all doctors use social media because of the benefit it can add for marketing and business development purposes. Beyond this marketing utility, however, some research has shown that getting information from a doctor after an in-person consultation can make patients more likely to take medicine properly and follow their physician’s instructions.

If you’re ready to get social--social networking, that is--you should prioritize knowing your audience and its habits first, before you ever log in to Facebook or LinkedIn. This involves knowing whether or not they even use social media, first of all. Then, you should figure out what they would like to learn about from you. An easy way to find this out might be to leave a quick paper survey in the waiting room for patients to fill out. Once you know that your patients are on social networks and know what kind of information they’d like, you should identify what kind of content will appeal to them:

Think about your audience. For example, if you’re a pediatrician, preteen patients will probably appreciate links to YouTube videos where Justin Bieber talks on the importance of an active lifestyle. But if you’re a physician serving largely college-aged patients, sharing the Bieber video would paint you as out-of-touch.

The next step is to create a schedule and publish regularly. Start out with a Facebook business page that links to your practice website. Then make the move up to LinkedIn, and create a strong profile that accurately reflects your experience, before you reach out to your current and former colleagues. After you’re publishing one to two times each week and feel comfortable at this rate, you can round out your social media presence with a Twitter account. If you approach social media with the intention of creating a two-sided conversation, and you know what kind of information your patients like to hear, you’ll be in good shape.

To read the rest of the article, you can check out the entire post on the Software Advice Blog.

###

Katie Matlack is the Medical Market Analyst for Software Advice, a company that helps people make choices on electronic medical records software and health information technology.

]]> http://www.physiciansnews.com/2011/12/23/attract-patients-keep-them-healthy-with-social-media/feed/ 0 Year-End 2011 Tax Planning for Physicians http://www.physiciansnews.com/2011/12/13/year-end-2011-tax-planning-for-physicians/ http://www.physiciansnews.com/2011/12/13/year-end-2011-tax-planning-for-physicians/#comments Tue, 13 Dec 2011 15:15:24 +0000 Physicians News http://www.physiciansnews.com/?p=4483 [/caption] By Michael Kline, CPA As the year draws to a close, it is time for medical practices and medical professionals to review the current year’s financial activity and determine if any tax planning opportunities are available to help reduce their overall tax burden. Below are some tax planning tips that can be utilized before year-end that can greatly reduce your tax burden. Depreciation The biggest and easiest 2011 tax-saving opportunity is the accelerated depreciation available until the end of 2011. For many physicians, the purchasing of new equipment can give rise to large deductions in the year the equipment is purchased. Depreciation can be accelerated based on two available tax provisions: bonus depreciation and Section 179 expensing. Bonus depreciation. For qualified assets acquired and placed in service through Dec. 31, 2011, the additional first-year depreciation allowance is 100%. Among the assets that qualify are new tangible medical equipment, computers and off-the-shelf computer software. Additionally, some leased equipment may also qualify, depending on the terms of the lease. With a few exceptions, bonus depreciation is scheduled to drop to 50% in 2012. You may want to purchase and place in service qualifying assets by Dec. 31. Section 179 expensing. This election also allows a 100% deduction for the cost of acquiring qualified assets, but is subject to different rules than bonus depreciation. Unlike the bonus depreciation, used assets can qualify for Section 179 expensing. However, a couple of rules may make Section 179 expensing less beneficial for a medical practice:
  • For 2011, expensing is subject to an annual limit of 0,000, and this limit is phased out dollar for dollar if purchases exceed million for the year. So larger medical practices may not benefit.
  • The election cannot reduce net income below zero. So for businesses that are having a bad year, it can’t be used to create or increase a net operating loss for tax purposes.
The expensing and asset purchase limits are scheduled to drop to 5,000 and 0,000, respectively, in 2012 (though both amounts will be indexed for inflation). Although taking bonus depreciation and/or Section 179 expensing deductions now gives you and your practice immediate deductions for your equipment purchases, it also means you are forgoing deductions that could otherwise be taken later as normal depreciation. In some situations, future deductions could be more valuable. For example, tax rates for individuals are scheduled to go up in 2013, which means flow-through entities, such as partnerships, limited liability companies and S corporations, might save more by deferring the deductions. Retirement plan contributions Many medical practices offer retirement contribution plans, such as 401(K) plans, for their employees. In 2011, the maximum amount that can be contributed by an employee is ,500 and ,000 for participants over 50 years old.  By adding a profit sharing plan in addition to a 401(K) plan, owners of medical practices can increase the amount contributed toward their retirement to ,000.  Although the practice would need to make a contribution for all eligible employees, the plan may be able to be structured to allow most of the contribution by the practice to go the owners. Additionally, the contribution, while deductible on the 2011 tax returns, does not have to be paid until the due date of the practice’s tax return, including extension. Individuals: Income, expenses and AMT Traditional income tax planning calls for deferring income to the next year and accelerating expenses into the current year. This defers taxes to the next year, which generally is beneficial — as long as you’ll be subject to the same (or a lower) marginal rate. Because the 2010 Tax Relief Act extended lower rates through 2012, in 2011 you have the opportunity to take advantage of this traditional strategy (unless you expect to move into a higher tax bracket next year). Potentially controllable income and expense items include:
  • Bonuses or self-employment income
  • State and local income and real estate taxes
  • Mortgage interest
  • Charitable contributions
But this opportunity isn’t without a challenge. Before taking action to time income and expenses, you must consider the alternative minimum tax (AMT). It’s a separate tax system that limits some deductions and doesn’t permit others, such as for state and local income, and real estate taxes and miscellaneous itemized deductions. It also treats certain income items differently. You must calculate your tax liability under both the regular and the AMT systems, and pay the AMT if your AMT liability is higher. So without proper planning, deferring income or accelerating deductions could trigger the AMT or increase AMT liability this year or next. The acceleration of some deductions, such as state and local taxes and some unreimbursed business expenses, could provide you no tax benefit if you are subject to AMT tax. Further complicating matters is the fact that, unlike the regular tax system, the AMT system isn’t regularly adjusted for inflation. Instead, Congress must legislate any adjustments. Typically, it has done so in the form of a “patch.” Such a patch is in effect for 2011 but not for 2012. This makes planning for the AMT — and thus properly timing your income and deductions — especially challenging this year. Gifting and estate planning While estate planning won’t necessarily affect your income tax bill, it’s a good idea to also consider your estate planning goals as year-end approaches. For example, the annual exclusion allows you to gift up to ,000 per year per recipient, gift-tax-free without using up any of your lifetime gift and estate tax exemptions. But unused exclusions don’t carry forward. For example, if you miss the Dec. 31 deadline for making an annual exclusion gift to a particular family member, you cannot make double the gift under the exclusion the next year to make up for it. Also consider the million lifetime gift tax exemption. Although action by Dec. 31, 2011, isn’t required, action by Dec. 31, 2012, may well be. The exemption is scheduled to drop to million on January 1, 2013. The million exemption presents an unprecedented opportunity to transfer substantial wealth to your loved ones tax-free. It may be especially valuable if you are holding assets you expect to increase significantly in value. Making a gift now will remove not only the assets’ current value from your taxable estate, but also all future appreciation on them. Achieve your tax planning goals We’ve discussed only a few of the 2011 tax planning opportunities and challenges. And it’s possible that tax legislation could be signed into law between now and Jan. 1, 2012, that would extend expiring tax breaks or make other changes for 2012 that would affect your 2011 year-end strategies. Further, changes in the economy, the markets or your personal situation could also have an impact. It’s critical to review your tax situation now with your tax advisor and revisit it if anything changes. ### Michael J. Kline is a Certified Public Accountant. A partner in Citrin Cooperman’s Philadelphia office (www.citrincooperman.com), Kline is responsible for client service and quality control, and consults with clients on issues including ownership structure, entity decisions, audits, and multi-state tax and succession planning. Kline can be reached at mkline@citrincooperman.com or 215-545-4800.  ]]> http://www.physiciansnews.com/2011/12/13/year-end-2011-tax-planning-for-physicians/feed/ 0 How to Protect Your Practice From Your Spouse http://www.physiciansnews.com/2011/12/06/how-to-protect-your-practice-from-your-spouse/ http://www.physiciansnews.com/2011/12/06/how-to-protect-your-practice-from-your-spouse/#comments Tue, 06 Dec 2011 15:28:48 +0000 Physicians News http://www.physiciansnews.com/?p=4466 By Deborah B. Miller, Esq.

From a personal perspective, prenuptial agreements are not very appealing, but from a common sense and legal point of view, they can be essential. Getting married is the biggest financial decision in most people’s lives, but many do not consider the financial entanglements that marriage creates.  Just ask anyone who has lost a house or retirement plan in a divorce. Despite reading articles about the importance of using a prenuptial agreement as a tool for planning, plenty of people feel uncomfortable with prenuptial agreements.  Luckily, there are secondary measures, not all as good as a prenuptial agreement, but perhaps more in line with your personal views and the realities of your relationship.  For example, there are ways to structure corporate documents to insulate your medical practice from divorce proceedings, whether your own divorce or that of another physician in your practice.  Buy-sell agreements among shareholders and corporate insurance policies in the event of a forced buyout can be effective tools to protect the practice.  Likewise, postnuptial agreements are an option, even if the prenuptial agreement seemed awkward at the time of marriage.  A postnuptial agreement can be limited to a spouse relinquishing claims on your interest in your medical practice.  This can be a mandatory prerequisite for membership in a practice group, essentially forcing all group members to enter either prenuptial or postnuptial agreements to protect the medical practice from divorce.  This can be effective, as the pressure to enter such an agreement is external, and the blame for needing a postnuptial agreement can be shifted to the attorney for the medical practice.  It’s easy to blame the attorney, just give it a try. Everyone (whether married or not) should make sure their estate plans are up to date and there are a variety of situations in which prenuptial agreements should part of those estate plans.  The most important of these situations are a second marriage, or where at least one spouse has children before the marriage. Let’s start with what happens in a second marriage from a social perspective.  Statistics tell us that 2 out of 3 second marriages fail.  Yet hope springs eternal, as does love, and plenty of divorced folks get remarried.  Those who remarry are more experienced than the first time around, having learned either personally or through a friend the expense and stress associated with a difficult divorce.  Most people have heard about prenuptial agreements, but may not understand how a prenuptial agreement can help them avoid a long and costly divorce, while also protecting their Estate for their children.  Essentially, a prenuptial agreement should streamline a divorce in the event the marriage does not work out, having resolved the marital financial issues before the marriage.  The prenuptial agreement, however, will not address the issues as to any children of the marriage, such as child support and custody.  What it can do for you is to protect your medical practice, your salary, your pension and your retirement account.  It can state how the marital home is to be handled and what property is separate property.  The significance of protecting your medical practice from equitable distribution during a divorce, and your salary from years of alimony cannot be understated. A prenuptial agreement can set forth the financial parameters of the marriage from the day of the wedding up through and including how your Estate is handled after you die.  It can state whether your spouse has a right to an interest in your retirement benefits and your medical practice.  It can state whether or not your spouse waives the right to claim spousal support or alimony.  Some couples do not agree on a straightforward waiver of rights, but instead agree on a sliding scale—the longer the marriage lasts, the greater a dependent spouse’s entitlement to a portion of specified marital property. In addition to setting the financial parameters of your marital relationship, a prenuptial agreement is the best tool to prevent your Estate from ending up in the hands of someone else’s children.  Let’s consider Mom, who at 65 looks great (because she follows her family physician’s advice).  Last year, she married Bob.  Mom has a son and a daughter, but Mom did not get around to having a pre-nuptial agreement...so what happens when Mom dies before Bob and she does not have a will?  If Mom is a resident of Pennsylvania, we need to consider Bob’s statutory right of election.  This law allows, but does not require, Bob to “elect” to take 1/3 of Mom’s Estate.  The right of election exists whether or not Mom has a Will, and regardless of what Mom leaves Bob in her Will.  The only way to cancel this right is by agreement between Mom and Bob. If Bob elects against Mom’s will, he gets 1/3 of Mom’s assets that pass through her Will. Let’s say Mom’s Estate assets are a 0,000 investment account, and her house worth 0,000—a total of 0,000—essentially the money Dad made through hard work and careful saving.  This means that Bob gets 0,000, Mom’s son inherits 0,000, and Mom’s daughter inherits 0,000. Did Mom want Bob to get 0,000 from her Estate? Didn’t Mom always say she would leave everything to her children 50/50? A simple solution would have been a prenuptial agreement stating that Mom and Bob mutually waive their rights to each other’s Estates, including a waiver of their statutory right to claim an Elective Share.  Or, if there was no prenuptial agreement, a post-nuptial agreement is another option.  The agreement to waive the elective share need not occur before the marriage. In the event Mom does not want to leave Bob without anything, Mom and Bob can explore options that express loyalty and respect for her late husband and their children, as well as for Bob’s well-being after she dies.  For example, Mom may wish to grant Bob a life estate in her home, so long as he pays upkeep and taxes or may want to fund a testamentary trust from which Bob can obtain income and support after her death.  Depending on Mom’s wishes and the situation, this can be accomplished in a prenuptial agreement, a Will or by Deed. In second marriages, using Mom above as the ongoing example, there is a particular need to address where Mom will be buried.  If she does not make her intentions as to her remains firmly known, then Pennsylvania law allows Bob as the surviving spouse the unfettered right to decide where she will be buried.  Bob might want her to be buried in Florida near his winter condo.  Mom’s children, however, may want Mom to be buried next to Dad in the established family plot in Pennsylvania.  To resolve this issue, Mom can state her intentions as to her remains in her Will. There are plenty of other marital issues that can be addressed with other proper estate planning tools.  For example, a prenuptial agreement cannot protect Bob’s Estate from bills owed to third parties who provided Mom with “necessaries” such as a hospital care.  Nor can a prenuptial agreement protect Bob’s Estate from the Commonwealth of Pennsylvania seeking dollar-for-dollar reimbursement for all Medicaid benefits provided to Mom.  Depending on which issues are relevant to each couple, there are estate planning tools that can be used to address the various concerns, including placing monies in an irrevocable inter vivos trust. Second marriages involving younger couples are equally fraught with their own types of financial concerns that benefit from a prenuptial agreement.  In the case of younger couples who remarry with children from a prior marriage, the prenuptial agreement should address the thorny issues of how income and assets will be allocated to children and step-children for things ranging from medical expenses, to college tuition, to legal fees for custody and child support proceedings.   ###   Deborah B. Miller, Esquire, is a partner at Strong, Stevens, Miller & Wyant, P.C. (www.strongfirm.com). For follow up, please contact Debbie directly at (610) 239-8600 x 234 or dmiller@strongfirm.com  ]]> http://www.physiciansnews.com/2011/12/06/how-to-protect-your-practice-from-your-spouse/feed/ 0 Uncertainty Doesn’t Have to Mean Loss of Control for Physicians http://www.physiciansnews.com Tue, 07 Feb 2012 16:44:06 +0000 en hourly 1 http://wordpress.org/?v=3.2.1 Physicians News » Featured http://www.physiciansnews.com Tue, 07 Feb 2012 16:44:06 +0000 en hourly 1 http://wordpress.org/?v=3.2.1 Help Your Patients Get the Benefits They Deserve http://www.physiciansnews.com/2012/02/01/help-your-patients-get-the-benefits-they-deserve/ http://www.physiciansnews.com/2012/02/01/help-your-patients-get-the-benefits-they-deserve/#comments Wed, 01 Feb 2012 19:07:18 +0000 Physicians News http://www.physiciansnews.com/?p=4583 [/caption] By Eric A. Shore, J.D. and Pia Horton Everyday your patients trust you to care for their health. Many of your patients find themselves unemployed and therefore, uninsured. While some will find work eventually, those with physical and/or mental limitations may not. This is especially true for those approaching retirement age (50-65 years). You can help. Patients who are unable to sustain work due to their health may be eligible for Social Security disability benefits, therefore making them eligible for Medicare or Medicaid. Although treating your patients is obviously your primary concern, taking a few steps to encourage patients to apply and obtain Social Security benefits may be necessary for them to afford the care you provide. Physicians play an instrumental role in helping their patients obtain the Social Security disability benefits they need.  Social Security disability claims are evaluated by determining whether your patient suffers from a severe physical and/or mental impairment that has lasted and/or will last for twelve (12) months, and/or result in your patient's death.  Judges and attorneys review your medical records, looking for your specific documentation of your patient’s physical and mental limitations and how those limitations are caused by your patient's impairments.  To be most helpful, your medical records should also indicate how those limitations prevent or restrict your patient's ability to function on a daily basis. The severity and duration requirements can only be proven by obtaining proper medical evidence, as medical evidence is key to any successful Social Security Disability claim.  Social Security cases are often built and won on the strength of the medical records provided by a client’s treating physician.    Therefore, detailed progress/treatment notes, an accurate accounting of your patient's subjective complaints, referrals to specialists, and referrals for objective testing are necessary to build a winning claim. Your treatment notes are an important part of building the strength of your patient's case.  Consistent treatment should be documented with detailed narratives that include the following: specific dates of treatment, your diagnosis, the nature of your patient’s illness, its etiology, severity, and to what degree the impairment limits your patient’s ability to perform day to day activities, function on a job, and/or maintain full time employment. For example, if your patient has COPD and experiences severe dyspnea, chest pains, wheezing, and fatigue upon minimal exertion, indicate all in your treatment narratives.  Further indicate that medium and heavy exertional level activities are not recommended for your patient, and document specific functional restrictions and/or precautions that your patient should exercise on a daily basis.   Also, note why your patient should not partake in specific exertional activities.  For example, "due to Chronic Obstructive Pulmonary Disease, my patient’s lung volume capacity is severely compromised.  My patient should not lift any weight over ten (10) pounds frequently; never climb ladders; never walk for more than five (5) minutes; avoid vacuuming, dusting, mopping, and standing for more than thirty (30) minutes at a time; avoid all exposure  to dust, chemicals, or other environmental hazards."  Also indicate what adverse effects your patient will experience if he or she partakes in any of the restricted activity Your patient’s subjective complaints are extremely important to record upon every visit to your office.  Often, subjective complaints suggest the true severity of your patient’s impairment and how the impairment limits his or her ability to function.  Subjective complaints of chronic and severe pain should prompt further objective testing, physical therapy, and/or referrals to specialists. The results of objective tests offer concrete evidence that cannot be disputed.  Making timely and accurate referrals for CT scans, MRI’s, and X-rays can strengthen your patient’s case and provide and further confirm your diagnosis.  In addition, timely referrals to specialists and physical therapists document the severity of your patient’s impairment and can significantly increase the chances of winning the claim by indicating your patient’s need for ongoing care and treatment.  With the proper referrals, your patient can build a well documented treatment history, which will in turn bolster your patient’s credibility and increase his or her chances of success.  Moreover, timely objective testing can show permanent impairments, helping to satisfy both the severity requirement and the twelve (12) month duration requirement.  For example, frequently a patient who suffers from severe asthma and/or airway restriction disease is referred for a  Pulmonary Function Testing (PFT).  The results of an initial PFT may only show a mild impairment.  However, over the course of time, your patient's complaints and symptoms may worsen requiring you to refer them for further testing.  Subsequent tests can document how your patient's illness has progressed from tolerable to disabling. Often times, physicians note that their patient is applying for disability benefits, but do not indicate whether they have observed whether their patient is disabled.  Therefore, your observations of how your patient’s impairments affect them should be documented, as well. For example, noting that your patient walks with a limp, experiences frequent falls, has difficulty getting on or off of your examining table, was short of breath walking a short distance, heard voices, could not focus during your exam, could not walk from the waiting room to the treatment room without assistance, winces in pain to your touch, or requires assistive devices to ambulate, can benefit your patient’s claim. When your observations are consistent with your patient's subjective complaints and objective test results, the strength of your patient's claim increases substantially. Moreover, completing simple questionnaires or residual functional capacity (RFC) forms indicating how your patient’s impairments limit their ability to function can be invaluable to your patient’s claim.  Residual Functioning Capacity (RFC) forms and/or Medical Source Statement (MSS) are of great importance to any Social Security disability claim.  The forms help Social Security to evaluate the functional limitations caused by your patient's impairments by giving us insight into how those impairments limit the ability to perform work related activities.  The form consists of a list of physical or mental activities allowing the treating physician to assess their patient's ability to perform work related activities by indicating how the patient’s ability to function is limited by his or her impairment.  More importantly, the form contains sections that allow you to further comment on your patient's limitations in a brief narrative.  In a sense, the form gives you an opportunity to be present at your patients hearing. A supported RFC form completed by you may be the most influential piece of evidence in the case and may actually determine whether your patient will receive the benefits they need.  We know completing forms and copying records for legal matters are not a primary concern. However, because your assistance can be the deciding factor in whether your patient will obtain Medicare/Medicaid and the cash benefits needed to afford transportation to your office, helping patients with their Social Security disability and SSI cases is different. The Social Security Administration must consider all medical evidence of record in your patient's claim including your records and opinions, and give great weight to all evidence submitted by you, the treating physician.  Therefore, your observations, recommendations, referrals, and treatment plans are crucial in assessing your patient’s case and achieving the favorable outcome your patient needs and deserves. ### The Law Offices of Eric A. Shore, P.C. (www.1800cantwork.com) focuses on matters of Social Security Disability and SSI benefits.  They can be reached at 215.627.9999.    ]]> http://www.physiciansnews.com/2012/02/01/help-your-patients-get-the-benefits-they-deserve/feed/ 1 Practical Implications of Telemedicine Credentialing http://www.physiciansnews.com/2012/01/30/practical-implications-of-telemedicine-credentialing/ http://www.physiciansnews.com/2012/01/30/practical-implications-of-telemedicine-credentialing/#comments Mon, 30 Jan 2012 20:03:46 +0000 Physicians News http://www.physiciansnews.com/?p=4569 By Lucia Francesca Bruno, J.D., LL.M., M.B.A. For the past century, information technology has reinvented the familiar and revolutionized the art of medicine.  As health care professionals struggle to keep pace with an ever-changing and consolidating industry, traditional forms of health care have succumbed to modern technology and fiscal constraints.  No longer are patients and providers afforded the luxury of being in the same place at the same time.  Recent developments in patient-service delivery systems have transformed the doctor/patient relationship; paving the way for advances in telemedicine and the credentialing and privileging of telemedicine practitioners.  Inside Look into Telemedicine The Centers for Medicare and Medicaid (“CMS”) defines telemedicine as “the provision of clinical services to patients from a distance via electronic communications.”[1] Although telemedicine is not considered a medical specialty, products and services unique to this practice of medicine often require a costly investment in information technology and the delivery of clinical care by health care providers. Telemedicine seeks to improve a patient’s health by permitting two-way, interactive, communication between the patient and the physician, at a distant-site, for purposes of assessment, diagnosis, and intervention.  Examples of telemedicine include, but are not limited, to the following:  videoconferencing; transmission of still images, and remote monitoring of vital signs. A Past Marred by Obstacles Historically, smaller hospitals and Critical Access Hospitals (“CAHs”) desiring to take advantage of this cost-effective form of clinical care were hampered by duplicative and burdensome Conditions of Participation (“CoPs”) and redundant regulations.   In particular, the credentialing process of obtaining and reviewing practitioner data such as licensure, training, certifications, insurance, and National Practitioner Data Bank queries created a financial burden many hospitals simply could not afford.   Furthermore, many lacked the clinical expertise within their medical staff to evaluate and grant privileges to physicians providing telemedicine services. In a notorious policy brief issued by the National Rural Health Association (“NRHA”) in 2010, providers maintained that “the current telehealth credentialing process was more than an annoyance; it was a deterrent for providers and hospitals, and a barrier to expanding health care access.”[2]  NRHA urged CMS to “adopt a policy that allowed telemedicine providers to receive deemed status (as having met Medicare/Medicaid certification requirements) and permit health care facilities receiving telehealth services to perform credentialing by proxy (delegated credentialing).”[3]  NRHA surmised that “if a provider was already credentialed at a Medicare-participating facility, that credential would be sufficient to provide telemedicine services at another facility; while, the privileging process would remain the responsibility of the originating health care facility.”[4] A Future Swayed by Reason Acknowledging the need for transformational change, on May 5, 2011, CMS introduced the final rule which superseded prior Joint Commission privileging recommendations, and considerably streamlined the credentialing and privileging process for physicians providing telemedicine services. [5] The final rule, effective July 5, 2011, made Federal requirements more flexible and encouraged innovative approaches to the delivery of patient-services; thereby, allowing patients to receive medically necessary interventions in a timelier manner.[6]   In addition to taking a more lenient approach to CoPs, CMS expanded the platform of telemedicine by defining key terms and requiring a written agreement between the "patient-site" and the "distant-site."   The written agreement, subject to disclosure to CMS, must include specific elements and evidence the telemedicine practitioner’s privileges at the “distant-site.” Key Terms Defined by CMS “Telemedicine” is defined as “the provision of clinical services to hospital or CAH patients by practitioners from a distance via electronic communications, either simultaneously or non-simultaneously.”[7] “Simultaneous” telemedicine services are performed in real-time, similar to the actions of an on-site practitioner when called in by an attending physician to see a patient, e.g., teleICU services. [8] “Non-simultaneous” services are clinical services provided to the patient upon a formal request from the patient’s attending physician or practitioner; such services may involve after-the-fact interpretation of diagnostic tests and do not necessarily require the telemedicine practitioner to directly assess the patient in real-time, e.g., teleradiology services.[9] “Distant-site” the location at which the physician or other licensed practitioner delivering the service is located at the time the service is provided via telecommunications.  A “distant-site” is either a Medicare-participating hospital or telemedicine entity (non-Medicare participating hospital) that provides contracted telemedicine services in a manner that enables the hospital or CAH using telemedicine services to meet all applicable CoPs; particularly, those related to the credentialing and privileging of telemedicine practitioners. [10] Written Agreement Required:  Distant-Site Hospital When the distant-site is a Medicare-certified hospital, the final rule requires that the hospital or CAH have a written agreement that expressly states that it is the responsibility of the distant-site hospital to meet the credentialing requirements of 42 C.F.R. 482.12(a)(1)-(a)(7) for hospitals or 42 C.F.R. 485.616(c)(i)-(c)(vii) for CAHs.  In addition, the written agreement must contain the following: (i) the distant-site hospital is a Medicare-participating hospital; (ii) the distant-site practitioner is privileged at the distant-site hospital as evidenced by a current list of the practitioner’s privileges provided by the distant-site hospital; (iii) the practitioner holds a license issued and/or recognized by the state in which the hospital or CAH whose patients receive telemedicine services is located; and (iv) the hospital that credentials and privileges the distant-site practitioner disclose the practitioner’s performance information, e.g., adverse events, complaints, and internal reviews. Written Agreement Required:  Distant-Site Telemedicine Entity To rely on the credentialing and privileging decisions by a distant-site telemedicine entity, the distant-site must affirm, in writing, that the telemedicine entity is a contactor of services to the hospital and furnishes contracted services in a manner that permits the hospital to comply with all applicable CoPs, 42 C.F.R. 482.12(a)(1)-(a)(7) for hospitals or 42 C.F.R. 485.616(c)(i)-(c)(vii) for CAHs.  In addition, the written agreement must contain the following: (i) the distant site’s credentialing and privileging process at least meet the standards in 42 C.F.R. 482.12(a)(1)-(a)(7) and 42 C.F.R. 482.22(a)(1)-(a)(2) when the originating-site is a hospital or 42 C.F.R. 485.616(c)(1)(i)-(c)(1)(vii) when the originating-site is a CAH; (ii) the distant-site practitioner has the experience and expertise as represented by the distant-site telemedicine entity; (iii) the practitioner holds a license issued and/or recognized by the state in which the hospital or CAH is located; and (iv) the hospital or CAH has evidence of an internal review of the distant-site practitioner’s performance of privileges to be exercised at the hospital or CAH; conversely, the hospital or CAH  must send the distant-site entity performance information for use in the entity’s periodic appraisal of the distant-site practitioner. Effect on State Licensure Despite the sweeping reform brought about by the final rule, CMS cautioned that all state-based physician licensure requirements will remain unchanged. Recognizing the fact that “licensure laws and regulations have traditionally been, and continue to be, the provenance of individual States, the final rule does not pre-empt State authority.”[11] Although states remain split on the issue of telemedicine, many states espouse that their existing laws adequately reflect their position on the licensure of telemedicine practitioners.  Other states, however, affirm that a full and unrestricted license is necessary to practice telemedicine, and have reinforced that stance in law or policy.[12] In an effort to address growing concerns amongst medical professionals, the American Medical Association (“AMA”) reaffirmed its policy to support state-based licensure for physicians and oppose national licensure approaches to telemedicine. In its annual assessment of physician licensure, the AMA declared that “telemedicine in particular has crystallized the tension between the states’ role in protecting patients from incompetent physicians and protecting in-state physicians from out-of-state competition, and the desirability of ensuring patients’ access to the highest quality medical advice and treatment possible, wherever located.” [13] Despite tension between the states’ power to regulate health care professionals and the prohibition against restraint on interstate commerce, the practice of telemedicine has yet to be addressed by the courts.  Only time will tell if the final rule is sufficient to spur litigation in this cutting-edge practice of medicine. Informed Consent Considerations Despite comments to CMS encouraging patient informed consent be obtained before the use of telemedicine services by a hospital or CAH, CMS affirmed that under the final rule “there is no difference between distant-site practitioners and in-house or on-site practitioners with respect to informed consent.”[14]  CMS reiterated that “as long as the telemedicine practitioner is performing his or her duties within the privileges granted by the hospital or CAH, in accordance to a policy that requires informed consent, then consent must be obtained regardless of whether treatment is furnished by telemedicine or not.”[15]  For providers, this insightful decision alleviated one more instance of costly red tape.  Medical Staff Bylaws and Standard Operating Procedures In order to ensure full compliance and avoid unnecessary complications, providers are encouraged to amend medical staff bylaws and revise policies and procedures related to credentialing and privileging.  In particular, medical staff bylaws should contain current definitions relevant to telemedicine and an accurate description of the information-sharing process.  Medical staff bylaws should also reflect administrative changes to the provider’s Credentials Committee and Medical Executive Committee, especially as it pertains to clinical services provided by telemedicine. Furthermore, medical staff policies and procedures should be amended to account for changes in clinical protocols, insurance coverage, billing and reimbursement, and HIPAA compliance.   As a precautionary measure, any medical staff policies that require the “physical presence” of a physician should be reevaluated to account for the delivery of patient services by electronic communications. Finally, under the final rule, hospitals and CAHs that take advantage of privileging by proxy must disclose privileged peer review information to the distant-site.  Therefore, it is advisable that hospitals and CAHs carefully assess state-specific peer review guidelines and include language in the written agreement that ensures ongoing protection of peer review information. Conclusion There is no doubt that sweeping changes in the credentialing and privileging process has paved the way for greater advances in telemedicine services.   Dale Alverson, M.D., past president of the American Telemedicine Association surmised that “the final rule will truly help patients receive the care they need, no matter where they live or where their doctor is located.”[16] By eliminating the overly burdensome credentialing and privileging rules in Medicare, Dr. Alverson concluded that “CMS has shown growing support of telemedicine.” [17] Despite the obvious benefits to patients, the long-term ramifications of the final rule on providers are yet, unknown.  Hospitals and CAHs using telemedicine services of distant-site practitioners are, therefore, encouraged to implement adequate policies and procedures to protect their interests and those of their patients. ### Lucia Francesca Bruno, J.D., LL.M., M.B.A., is Principal Shareholder of Physicians’ Legal Group, LLC (www.physicianslegalgroup.com). She can be reached at Lbruno@physicianslegalgroup.com.  

[1] Medicare and Medicaid Programs: Changes Affecting Hospitals and Critical Access Hospital Conditions of Participation: Telemedicine Credentialing and Privileging, 76 Fed. Reg. 25, 551 (May 5, 2011).
[2] Lewis, Pam, Mandy Bell, BA,  Deanna Larson, RN, BSN, and  Jay Weems, MBA:  “Telehealth Provider Credentialing” National Rural Health Association Policy Brief (2010): 1-4.
[3] Lewis, Bell, Larson, Weems, Telehealth Provider Credentialing, 1.
[4] Id. at 1
[5]  Medicare and Medicaid Programs: Changes Affecting Hospitals and Critical Access Hospital Conditions of Participation: Telemedicine   Credentialing and Privileging, 76 Fed. Reg. 25,550, 25,551 (May 5, 2011).
[6] 76 Fed. Reg.  25,551.
[7] Id. at 551.
[8] Id.
[9] Id.
[10] Section 1834(m)(4)(A) of the Social Security Act
[11] 76 Fed. Reg.  25,557.
[12] Office for the Advancement of Telemedicine, “Telemedicine Licensure Report” (2003).
[13] American Medical Association, “Physician Licensure: An Update of Trends” American Medical Association, 2012. Web. 15 January 2012 http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/young-physicians-section/advocacy-resources/physician-licensure-an-update-trends.page.
[14] 76 Fed. Reg.  25,555.
[15] Id. at 255.
[16] http://learntelehealth.org/blog/post/final-ruling-on-credentialing-privileging-of-telehealth-providers/
[17] Id.
]]> http://www.physiciansnews.com/2012/01/30/practical-implications-of-telemedicine-credentialing/feed/ 0 Health Care Reform Debate: More Thought and Less Volume, Please http://www.physiciansnews.com/2012/01/26/health-care-reform-debate-more-thought-and-less-volume-please/ http://www.physiciansnews.com/2012/01/26/health-care-reform-debate-more-thought-and-less-volume-please/#comments Thu, 26 Jan 2012 15:58:22 +0000 Physicians News http://www.physiciansnews.com/?p=4556 By Erika Stewart Health care reform will make huge changes in the way insurance companies do business, but most of that will not go into effect right away. Provisions that will help most Americans in 2012 affect policies that were purchased after March 13, 2010. Under the new laws, health insurance companies cannot:
  • Refuse to cover children under age 19 who have a pre-existing condition
  • Impose a lifetime limit
  • Cancel a policy unless they can prove fraudulent information was given
  • Fail to provide an appeal process for denied claims
New insurance policies must now include reasonable preventive services that carry no copayment or deductible. This includes usual vaccinations, cancer screenings, well-child office visits, blood pressure checks, and tests for such chronic conditions as diabetes and high cholesterol. Children without insurance who have not reached the age of 26 can now be carried on their parents' insurance, even if they are married and no longer live with their parents. Newer health plans must allow the patient to choose a primary care physician and cannot require a referral for an OB/GYN service. The law also prohibits companies from requiring patients to go to a particular emergency room or get prior authorization for emergency care. Effects on Physicians While all this is good news for American families, what about the effect on doctors? Why was the bill endorsed by both the American Medical Association and the American Hospital Association? Primary care physicians will receive more pay from government-sponsored insurance such as Medicare for encouraging patients to take advantage of preventive and outpatient services likely to lower the overall cost of care for individuals. They will also receive incentives for providing coordinated care, and for using electronic health records so that patients are better understood. Hospitals will benefit from reducing the number of charity cases without any payment. By 2014 Americans will receive subsidies to help those with lower income afford medical insurance. Starting in 2014, Medicaid will cover most people who have less than 133 percent of poverty level income. This is projected to bring an additional 16 million people into that system. The impact on states will vary, depending on how generous the Medicaid program is there. The Federal government will cover the cost until 2020 but will then ask states to shoulder more of the burden. With many politicians eyeing cuts to Medicaid in order to bring the budget under control, the poorest of American citizens may be in jeopardy of losing some of their medical care. President Obama has promised to cut 0 billion. House Republicans, led by Paul Ryan, are pushing to change Medicaid to a block grant program and repeal the expansion of coverage. Sustainable Growth Rate (SGR) Another interesting aspect of our health care law is Medicare’s Sustainable Growth Rate (SGR). SGR is defined as the fastest rate at which an organization can grow without collapsing. This figure is used to adjust the Medicare fee schedule so that the fund does not become depleted. If expenditures exceed the SGR, the fee schedule is adjusted downward. However, the formula used does not take into account the increasing volume and complexity of care. A true reflection of program costs must take these factors into consideration. Some critics have complained that the health care reform law does not address this issue. That was not the focus of the bill, which deals mainly with issues of insurance coverage. As the debate about health care reform continues, doctors have weighed in both in favor of the law and concerned about its implications. On her blog “Barking Doc,” Maggie Kozel MD presents her perspective. She says, among other astute comments, that the discussion needs to focus on stewardship. As citizens of this wealthy nation, what is our responsibility? Dr. Kozel is author of “The Color of the Atmosphere: One Doctor’s Journey In and Out of Medicine.” After 10 year’s of practice in Navy medicine, Kozel entered private practice where she was confronted with the inequities of the current system and what that means in terms of patient care. Speaking of the relationship between doctor and patient, she writes, “conversation between doctor and patient is the most undervalued commodity in our health insurance system.” Whether the new law will survive attacks by conservatives, and how well it will address the needed changes in our health care system, remain to be seen. Thoughtful debate on the serious issues involved instead of bickering backed by special interests would help both Congress and the President focus on positive change. As Dr. Kozel writes, what is needed is more thought and less volume.                  ]]> http://www.physiciansnews.com/2012/01/26/health-care-reform-debate-more-thought-and-less-volume-please/feed/ 2 Camden Coalition’s Model for High Needs Patients http://www.physiciansnews.com/2012/01/09/camden-coalition%e2%80%99s-model-for-high-needs-patients/ http://www.physiciansnews.com/2012/01/09/camden-coalition%e2%80%99s-model-for-high-needs-patients/#comments Mon, 09 Jan 2012 15:33:37 +0000 Physicians News http://www.physiciansnews.com/?p=4529 By Jen Abraczinskas and Jeffrey Brenner, MD [caption id="attachment_4531" align="alignleft" width="100" caption="Jen Abraczinskas"][/caption] There is a lot of buzz about reducing hospital readmissions.  But what does a readmission look like?  And what will it take to provide the care needed to avoid readmissions? We arrived at the ICU to find our patient sedated and intubated. Yet only 10 days earlier Mrs. P was strong enough to navigate the halls in her wheel chair, had her diabetes and COPD under control and was taking her medications for bipolar disorder. Mrs. P was discharged with an abundance of home health services – nursing, physical therapy, occupational therapy, home health aid.  How had her condition declined so quickly?  We visited her on day three post-discharge.  Mrs. P was in her living room hospital bed covered in her own body fluids unable to turn herself.  We helped her husband clean her, dress her, and move her into a position where her lungs had a chance to fully expand.  We also checked her blood sugar – slightly over 250.  The rehab center had discharged her with sliding scale insulin and believed that her elderly husband knew how to administer it.  However, when we asked him to try, he only pulled up air into the syringe.  He was not strong enough or organized enough to take care of Mrs. P’s incredibly demanding health needs which required over 10 medications, multiple monthly doctors visits, special transportation, and help with daily living activities.  A 4-day lag in her home health agency opening her case was enough time for Mrs. P’s health status to go from good to seriously troubled. [caption id="attachment_4532" align="alignleft" width="96" caption="Jeffrey Brenner"][/caption] Mrs. P’s experience wasn’t a new one.  The ICU stay was her third admission to the hospital in the last three months.  Initially she had been hospitalized for a COPD exacerbation, sent to rehab, discharged home for several hours before a decline that required another hospital admission and then she repeated this cycle. She was frustrated. Her family was frustrated. And we were frustrated as we watched her careen between the best healthcare Camden has to offer and near neglect of her health needs.  The reasons for the cycle are complex with her greatest complication being our fragmented health system.  During her hospital and rehab stays her health improved because she was receiving daily assistance with her complicated medication regime. Following discharge her inability to use her glucometer, administer insulin, and understand her medications left her vulnerable to rapid health decline.  Since her admissions began, she had been disconnected from primary care and getting her into a new primary care doctor would take weeks.  As her husband battled his own health problems, she needed more assistance at home but did not qualify because her Medicaid application is only just started. Mrs. P’s suffering is also costly. During the last three months, Medicare paid over ,000 for Mrs. P’s 3 admissions, including 2 ICU stays, and 11 weeks of rehab.  Preventing her third readmission alone would have saved Medicare ,482.  Then there is the cost to Mrs. P and her family.  She kept losing the good health she would gain in rehab.  Her husband felt guilty and embarrassed that he could not provide the expert care his wife needed to stop cycling in and out of the hospital.   Sadly, Mrs. P. is not alone in her struggles to stay healthy and out of the hospital.  Everyday in the United States, 10,000 more people turn 65 and many will suffer with multiple chronic illnesses, trouble with transportation, and questions regarding what level of care they truly need.  This population will bill Medicare with its expenses and overburden families with its home health needs. To break the hospitalization cycle and to curb healthcare spending, the Camden Coalition of Healthcare Providers has developed an innovative care management model for high needs / high costs patients in Camden NJ.  The Care Management Team relies on home visits with patients to coordinate doctors’ appointments, transportation, and social services.  The Team provides holistic medical care as well as root cause analysis and solutions to the often intertwined issue of poverty and disease that plague its patients. At any given time the Team sees approximately 35-40 patients. We are often asked why we work so intensely on a hand-full of patients.  From analyzing data gathered from three hospitals in Camden, we found that 1 percent of patients account for 30 percent of costs.  If we focus on the heaviest utilizers of health care, connect them into primary care, and address their needs outside of hospitals, we can begin to bend the cost curve.  The numbers are convincing and inform our overarching mission. But every day we also see the faces of patients needing assistance.  It is our patients’ confrontation with or neglect from our fragmented, difficult to navigate healthcare system that fuels the change we are trying to make. The Care Management Team has seen great success with many patients.  For Mrs. P., we ensured home health arrived soon after her discharge from this ICU stay and continued to communicate with them.  We connected her to a new primary care doctor and arranged transportation to her appointments. We involved her family in a discussion about long term goals and are facilitating her entry into an adult day program.  For other patients, we’ve supported them to achieve permanent housing, affordable medications, and primary and specialty care appointments with doctors who they trust.  Yet, we realize that time-intensive care management often falls into the laps of ill-equipped, overburdened primary care providers, hospital residents or insurance companies.  The Coalition is working to supply providers with tools to reduce the time and cost associated with great care coordination.  The Coalition has developed the Camden Health Information Exchange (HIE) to coordinate the hospital discharge summaries, lab data, and radiology reports for Camden residents.  The Camden HIE allows providers to have up-to-date information on their patients’ conditions and eliminates the need to order repeat tests.  We also are positioning Care Coordination Teams in Camden primary care offices.  The Teams will focus on patients with diabetes or high health care utilization for whom extra care coordination support is needed. As we look to the future, working in a more coordinated fashion is the only way that the needs of our growing, aging population will be met in the United States.  In Camden, we are testing models to improve health care and social services navigation, reduce unnecessary utilization, and equip providers with health information and coordination teams.  If we can support patients in their efforts to attain good health, we will decrease costs and be able to provide more and higher quality services for all. ### The Camden Coalition of Healthcare Providers (www.camdenhealth.org) was created with the overarching mission to improve the health status of all Camden, NJ residents, by increasing the capacity, quality, and access of care in the city.   Jen Abraczinskas is a third year medical student at the University of Pennsylvania and is spending a year with the Coalition as an Americorp volunteer.  Jen is a health coach with the Coalition's high utilizer project. Jeffrey Brenner, MD, is Director, Institute for Urban Health at Cooper University Hospital and Executive Director, Camden Coalition of Healthcare Providers. Naomi Wyatt, the Coalition's Director of Legal and Governmental Affairs, contributed to this article.]]> http://www.physiciansnews.com/2012/01/09/camden-coalition%e2%80%99s-model-for-high-needs-patients/feed/ 1 A Challenging Road Ahead for America’s Physicians http://www.physiciansnews.com/2012/01/05/a-challenging-road-ahead-for-america%e2%80%99s-physicians/ http://www.physiciansnews.com/2012/01/05/a-challenging-road-ahead-for-america%e2%80%99s-physicians/#comments Thu, 05 Jan 2012 15:20:33 +0000 Physicians News http://www.physiciansnews.com/?p=4508 By  Louis J. Goodman and Timothy B. Norbeck  This year promises to be a watershed year for healthcare in general, and for patients and physicians, in particular.  No matter how the U.S. Supreme Court determines the constitutionality of the Patient Protection and Affordable Care Act (PPACA), 2012 will be a crucial turning point in the delivery of healthcare. [caption id="attachment_4511" align="alignleft" width="150" caption="Louis J. Goodman, Ph.D."][/caption] During the Congressional passage of the PPACA, White House advisors acknowledged that the economic forces in the legislation would accelerate physician employment by hospitals and larger physician groups.  As mentioned in the “Roadmap for Physicians to Health Care Reform,” the “private” part of private practice for physicians is disappearing.  Currently, more than 80 percent of visits to physician offices have been to practices with five or fewer physicians.  That will change drastically as more physicians feel pressure to move into larger groups or become employed by hospital systems.  Through October of 2011, there have been 71 hospital mergers. All of this will change the face of the delivery aspect of health care, but a question remains: will it be for the better or worse? Expert opinion is almost universal that there is a present shortage of physicians, especially those in primary care and those practicing in rural areas.  This is a workforce problem that must be addressed now, but it seems to be lost in the debate over the PPACA.  The Physicians Foundation recognizes the shortage problem and recently awarded a large grant to The Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill to develop a dynamic web-based projection model that can be continually updated to track ongoing physician workforce needs across the country.  Information gleaned from the UNC research will further enhance efforts to identify where physicians are most needed to support patients in a growing healthcare system.  Thirty-six percent of practicing physicians are over age 55 and may retire by 2020.  According to Physician Foundation surveys conducted by Merritt Hawkins in 2008 and 2010, fewer physicians are seeing Medicare patients or taking on new Medicare patients.  With 10,000 baby boomers becoming eligible for Medicare every single day, the survey results do not bode well for access to care for Medicare patients. [caption id="attachment_4512" align="alignleft" width="150" caption="Timothy B. Norbeck"][/caption] Why do we have fewer physicians seeing Medicare patients at the very time that we need more of them?  First of all, the Sustainable Growth Rate (SGR) used to pay physicians under Medicare, singles out physicians for financial punishment in the form of payment reductions when volume of service increases.  With an aging population and increasing numbers of chronically ill elderly people, of course the volume of services continues to rise.  However, unless Congress steps in and acts promptly, Medicare physician payments are scheduled for an average reduction of 27.4 percent effective January 1, 2012.  The Physicians Foundation joins all other medical associations and the AARP in warning of the dire consequences on patients’ access to care should this massive and unwarranted reduction go through.  The fatally flawed SGR must be fixed and the aforementioned 27.4 percent scheduled reduction must be stopped. Much has been said about the PPACA, some good and some bad.  We would like to address the legislation from a physician’s point of view.  Physicians are extremely happy to have the American public insured and are delighted to have an end to the discrimination against their patients with pre-existing conditions. They also applaud the new focus on preventive care which should help lead to a healthier public.  As for the downside to the legislation, there was no SGR fix and no tort reform.  The PPACA also assumes a planned 30 percent reduction in physician fees scheduled under the SGR over the next three years.  Furthermore, and this is something that is largely overlooked when discussing the legislation, any physician’s office which mistakenly and by mere accident improperly bills too much for a Medicare visit, is subject to potential liability under federal fraud and abuse statutes. Before the PPACA, intent to commit fraud was necessary for a charge of fraud to be made, but now even an innocent error can result in prosecution.  Finally, and also overlooked by many, is the “translation” fee which must be paid by the treating physician.  If a physician treats a patient who doesn’t speak English and requires a translator, the physician is responsible for the translation fee.  In other words, the translator’s bill would probably exceed the physician’s reimbursement for the office visit! These issues and other pressures on physicians help explain some of the survey results from the 2010 Physicians Foundation Health Reform Research Study, and the numbers only become bleaker when comparing the results from our 2008 survey.  Only one-quarter of physicians surveyed said they plan to continue practicing as they are; while half reported that they would adopt a style of practice different from the traditional full-time independent private practice model.  Hence, the “private” in private practice is going, going, gone! Clearly, increasing administrative burdens attributable to the PPACA requirements plus insurance, red tape and costly regulatory measures are having a likely negative effect on patient care.  Sixty-three percent of physicians surveyed claimed that non-clinical paperwork has caused them to spend less time with their patients and 94 percent said that the time they devote to non-clinical paperwork has increased over the past three years.  Ask any physician what he or she enjoys the most about practicing medicine and the response will be: “seeing, helping and interacting with my patients.” The increasing amount of regulations and paperwork are becoming a more formidable barrier to the joy of practicing medicine.  Add to that the declining reimbursements and difficulty in sustaining one’s practice, the constant threat of liability, decreased time with patients and low or no bargaining power with insurers, it is not surprising to note that general physician morale is low and getting lower. A recent Robert Wood Johnson Foundation survey of physicians indicated that four out of five physicians agreed that unmet social needs are connected to declining health for many Americans. By the same ratio, they also agreed that addressing patients’ social needs are just as important as addressing their medical conditions.  An innovative Boston, Massachusetts organization called Health Leads interviewed local physicians about their needs in providing patient care.  Many expressed frustration that they could not help their poor patients beyond simply providing medical care – with housing, nutrition (food) or other resources that could improve their health.  Not only have these important issues been excluded from the health reform debate, they are largely ignored by policymakers. With a substantial grant from The Physicians Foundation, Health Leads has been able to expand their efforts to train college student volunteers in five cities to “assist” physicians to “prescribe” food, housing and fuel assistance, or other resources for their patients – just as they do medication.  Patients then take those “prescriptions” to the Health Leads Family Help Desks located in clinic waiting rooms, where the volunteers “fill” them by connecting patients with those resources.  Most of the student volunteers (64 percent of who are pre-med students) end up choosing to go into primary care – another plus! Generally exacerbating the overall workforce problem is the plight of medical students now coming into practice.  Graduates, on average, carry a debt of 6,000 and payments of up to ,000 a month!  According to the American Association of Medical Colleges (AAMC), each member of the graduating medical school class of 2033 will face a 0,000 debt! So what can be done to help physicians sustain their practices and have more time with their patients?  An obvious place to start would be to fix the unfair SGR – and promptly!  This Congressional and government inability to solve this problem reminds us of the late economist Milton Friedman’s observation on the inefficacy of government: If you put the government in charge of the Sahara Desert, he said, in five years there will be a shortage of sand.  And so it is with the growing shortage of physicians.  Congress should relieve physicians of onerous and time-consuming regulations and insurance red tape – which do not help patient care and only add to the cost of that care.  It should create more incentives for physicians to go into rural areas and find additional ways for medical students to pay off their medical school loans.  Build more medical schools and increase the number of the 25,000 residents and fellows completing their training every year. Of course, the big question is: Where do you find the money to do all this?  Throughout America’s history, that question has been asked many times.  The obvious answer: If you have the will you can find the wallet.  America always has, if the issue is considered important enough.  It won’t be easy but healthcare delivery and its workforce are being challenged in a major way today, and it will only worsen tomorrow without Congress stepping up and addressing it.  As noted in Shakespeare’s Henry VI: “Delays have dangerous ends.” ### Louis J. Goodman, PhD, is President and Timothy B. Norbeck is CEO of The Physicians Foundation, which is a nonprofit 501(c)(3) organization that seeks to advance the work of practicing physicians and to improve the quality of healthcare for all Americans. It pursues its mission through a variety of activities including grantmaking, research and policy impact studies. Since 2005, The Foundation has awarded numerous multi-year grants totaling more than million.  In addition, The Foundation focuses on the following core areas: health system reform, health information technology, physician leadership, workforce needs and pilot projects.  As the health system in America continues to evolve, The Physicians Foundation is steadfast in its determination to foster the physician / patient relationship and assist physicians in sustaining their medical practices during this evolution. For more information, visit www.physiciansfoundation.org.  ]]> http://www.physiciansnews.com/2012/01/05/a-challenging-road-ahead-for-america%e2%80%99s-physicians/feed/ 6 Physician Mind Shift: The Emergency Department in an ACO World http://www.physiciansnews.com/2012/01/04/physician-mind-shift-the-emergency-department-in-an-aco-world/ http://www.physiciansnews.com/2012/01/04/physician-mind-shift-the-emergency-department-in-an-aco-world/#comments Wed, 04 Jan 2012 20:51:50 +0000 Physicians News http://www.physiciansnews.com/?p=4519 By Mark Crockett, MD In the era of accountable care, you’ll notice that many hospitals and health systems are already driving towards more collaborative workflow. The integrated delivery network (IDN) is changing significantly, and for the better. But in high-acuity care areas, like the emergency department (ED), the challenge of treating patients more holistically in what is already a fast-paced environment is concerning for physicians evaluating the pay-for-performance model. In today’s ED, patients may enter with a chronic condition that could be better managed by a primary care physician (PCP), but because ED physicians are incented to treat sick people in a fee-for-service model, they continue to take these patients on instead of referring them outside the ED walls. If instead both ED and primary care physicians operate as part of a team of care givers that are incented to ensure patients stay healthy and avoid hospital admissions and readmissions, they are headed in the same direction in terms of focusing on better patient outcomes vs. reimbursement dollars. ED physicians used to be among the few physicians employed by the hospital, but that’s changing dramatically as IDNs snap up physician groups. The larger group working together will help make sure the ball isn’t dropped anywhere throughout the spectrum of care. If a patient with a laceration comes into the ED with diabetes, and that ED doc doesn’t think to check blood sugar – because that’s more of a PCP issue – that oversight will be visible in an ACO environment and the physician might be under the microscope in terms of the role played in ensuring quality outcomes. Part of this movement requires implementing integrated technology solutions that provide greater visibility into the types of care needed in your community, allowing the health system to build care facilities that are catered to the population it serves, ultimately enabling the sustainable health community. But the real lynchpin for success is the collaboration between people, not just IT systems. This means choosing metrics to support each constituency that has a stake in the game – providers, payers, physicians and patients – so that they buy into the new strategy and are empowered to make changes that support lower costs, increased efficiencies and higher quality care. It takes strong leadership demanding teamwork across clinical, administrative and even third-party vendors, along with a shared passion for making sure patients are cared for in the best possible way to make this happen. ### Mark Crockett, MD, is chief medical officer for Accountable Care Solutions at OptumInsight. He also practices emergency medicine at Advocate Good Samaritan Hospital in Downer’s Grove, Ill. He maintains a solid understanding of the day-to-day workings of an emergency department and the need for automating the documentation process of this intense environment.]]> http://www.physiciansnews.com/2012/01/04/physician-mind-shift-the-emergency-department-in-an-aco-world/feed/ 0 Attract Patients & Keep Them (Healthy) with Social Media http://www.physiciansnews.com/2011/12/23/attract-patients-keep-them-healthy-with-social-media/ http://www.physiciansnews.com/2011/12/23/attract-patients-keep-them-healthy-with-social-media/#comments Fri, 23 Dec 2011 15:18:46 +0000 Physicians News http://www.physiciansnews.com/?p=4504 By Katie Matlack Over on the Software Advice blog, we discussed ways doctors can use social media for a variety of purposes. A recent study reported over half of all doctors use social media because of the benefit it can add for marketing and business development purposes. Beyond this marketing utility, however, some research has shown that getting information from a doctor after an in-person consultation can make patients more likely to take medicine properly and follow their physician’s instructions.

If you’re ready to get social--social networking, that is--you should prioritize knowing your audience and its habits first, before you ever log in to Facebook or LinkedIn. This involves knowing whether or not they even use social media, first of all. Then, you should figure out what they would like to learn about from you. An easy way to find this out might be to leave a quick paper survey in the waiting room for patients to fill out. Once you know that your patients are on social networks and know what kind of information they’d like, you should identify what kind of content will appeal to them:

Think about your audience. For example, if you’re a pediatrician, preteen patients will probably appreciate links to YouTube videos where Justin Bieber talks on the importance of an active lifestyle. But if you’re a physician serving largely college-aged patients, sharing the Bieber video would paint you as out-of-touch.

The next step is to create a schedule and publish regularly. Start out with a Facebook business page that links to your practice website. Then make the move up to LinkedIn, and create a strong profile that accurately reflects your experience, before you reach out to your current and former colleagues. After you’re publishing one to two times each week and feel comfortable at this rate, you can round out your social media presence with a Twitter account. If you approach social media with the intention of creating a two-sided conversation, and you know what kind of information your patients like to hear, you’ll be in good shape.

To read the rest of the article, you can check out the entire post on the Software Advice Blog.

###

Katie Matlack is the Medical Market Analyst for Software Advice, a company that helps people make choices on electronic medical records software and health information technology.

]]> http://www.physiciansnews.com/2011/12/23/attract-patients-keep-them-healthy-with-social-media/feed/ 0 Year-End 2011 Tax Planning for Physicians http://www.physiciansnews.com/2011/12/13/year-end-2011-tax-planning-for-physicians/ http://www.physiciansnews.com/2011/12/13/year-end-2011-tax-planning-for-physicians/#comments Tue, 13 Dec 2011 15:15:24 +0000 Physicians News http://www.physiciansnews.com/?p=4483 [/caption] By Michael Kline, CPA As the year draws to a close, it is time for medical practices and medical professionals to review the current year’s financial activity and determine if any tax planning opportunities are available to help reduce their overall tax burden. Below are some tax planning tips that can be utilized before year-end that can greatly reduce your tax burden. Depreciation The biggest and easiest 2011 tax-saving opportunity is the accelerated depreciation available until the end of 2011. For many physicians, the purchasing of new equipment can give rise to large deductions in the year the equipment is purchased. Depreciation can be accelerated based on two available tax provisions: bonus depreciation and Section 179 expensing. Bonus depreciation. For qualified assets acquired and placed in service through Dec. 31, 2011, the additional first-year depreciation allowance is 100%. Among the assets that qualify are new tangible medical equipment, computers and off-the-shelf computer software. Additionally, some leased equipment may also qualify, depending on the terms of the lease. With a few exceptions, bonus depreciation is scheduled to drop to 50% in 2012. You may want to purchase and place in service qualifying assets by Dec. 31. Section 179 expensing. This election also allows a 100% deduction for the cost of acquiring qualified assets, but is subject to different rules than bonus depreciation. Unlike the bonus depreciation, used assets can qualify for Section 179 expensing. However, a couple of rules may make Section 179 expensing less beneficial for a medical practice:
  • For 2011, expensing is subject to an annual limit of 0,000, and this limit is phased out dollar for dollar if purchases exceed million for the year. So larger medical practices may not benefit.
  • The election cannot reduce net income below zero. So for businesses that are having a bad year, it can’t be used to create or increase a net operating loss for tax purposes.
The expensing and asset purchase limits are scheduled to drop to 5,000 and 0,000, respectively, in 2012 (though both amounts will be indexed for inflation). Although taking bonus depreciation and/or Section 179 expensing deductions now gives you and your practice immediate deductions for your equipment purchases, it also means you are forgoing deductions that could otherwise be taken later as normal depreciation. In some situations, future deductions could be more valuable. For example, tax rates for individuals are scheduled to go up in 2013, which means flow-through entities, such as partnerships, limited liability companies and S corporations, might save more by deferring the deductions. Retirement plan contributions Many medical practices offer retirement contribution plans, such as 401(K) plans, for their employees. In 2011, the maximum amount that can be contributed by an employee is ,500 and ,000 for participants over 50 years old.  By adding a profit sharing plan in addition to a 401(K) plan, owners of medical practices can increase the amount contributed toward their retirement to ,000.  Although the practice would need to make a contribution for all eligible employees, the plan may be able to be structured to allow most of the contribution by the practice to go the owners. Additionally, the contribution, while deductible on the 2011 tax returns, does not have to be paid until the due date of the practice’s tax return, including extension. Individuals: Income, expenses and AMT Traditional income tax planning calls for deferring income to the next year and accelerating expenses into the current year. This defers taxes to the next year, which generally is beneficial — as long as you’ll be subject to the same (or a lower) marginal rate. Because the 2010 Tax Relief Act extended lower rates through 2012, in 2011 you have the opportunity to take advantage of this traditional strategy (unless you expect to move into a higher tax bracket next year). Potentially controllable income and expense items include:
  • Bonuses or self-employment income
  • State and local income and real estate taxes
  • Mortgage interest
  • Charitable contributions
But this opportunity isn’t without a challenge. Before taking action to time income and expenses, you must consider the alternative minimum tax (AMT). It’s a separate tax system that limits some deductions and doesn’t permit others, such as for state and local income, and real estate taxes and miscellaneous itemized deductions. It also treats certain income items differently. You must calculate your tax liability under both the regular and the AMT systems, and pay the AMT if your AMT liability is higher. So without proper planning, deferring income or accelerating deductions could trigger the AMT or increase AMT liability this year or next. The acceleration of some deductions, such as state and local taxes and some unreimbursed business expenses, could provide you no tax benefit if you are subject to AMT tax. Further complicating matters is the fact that, unlike the regular tax system, the AMT system isn’t regularly adjusted for inflation. Instead, Congress must legislate any adjustments. Typically, it has done so in the form of a “patch.” Such a patch is in effect for 2011 but not for 2012. This makes planning for the AMT — and thus properly timing your income and deductions — especially challenging this year. Gifting and estate planning While estate planning won’t necessarily affect your income tax bill, it’s a good idea to also consider your estate planning goals as year-end approaches. For example, the annual exclusion allows you to gift up to ,000 per year per recipient, gift-tax-free without using up any of your lifetime gift and estate tax exemptions. But unused exclusions don’t carry forward. For example, if you miss the Dec. 31 deadline for making an annual exclusion gift to a particular family member, you cannot make double the gift under the exclusion the next year to make up for it. Also consider the million lifetime gift tax exemption. Although action by Dec. 31, 2011, isn’t required, action by Dec. 31, 2012, may well be. The exemption is scheduled to drop to million on January 1, 2013. The million exemption presents an unprecedented opportunity to transfer substantial wealth to your loved ones tax-free. It may be especially valuable if you are holding assets you expect to increase significantly in value. Making a gift now will remove not only the assets’ current value from your taxable estate, but also all future appreciation on them. Achieve your tax planning goals We’ve discussed only a few of the 2011 tax planning opportunities and challenges. And it’s possible that tax legislation could be signed into law between now and Jan. 1, 2012, that would extend expiring tax breaks or make other changes for 2012 that would affect your 2011 year-end strategies. Further, changes in the economy, the markets or your personal situation could also have an impact. It’s critical to review your tax situation now with your tax advisor and revisit it if anything changes. ### Michael J. Kline is a Certified Public Accountant. A partner in Citrin Cooperman’s Philadelphia office (www.citrincooperman.com), Kline is responsible for client service and quality control, and consults with clients on issues including ownership structure, entity decisions, audits, and multi-state tax and succession planning. Kline can be reached at mkline@citrincooperman.com or 215-545-4800.  ]]> http://www.physiciansnews.com/2011/12/13/year-end-2011-tax-planning-for-physicians/feed/ 0 How to Protect Your Practice From Your Spouse http://www.physiciansnews.com/2011/12/06/how-to-protect-your-practice-from-your-spouse/ http://www.physiciansnews.com/2011/12/06/how-to-protect-your-practice-from-your-spouse/#comments Tue, 06 Dec 2011 15:28:48 +0000 Physicians News http://www.physiciansnews.com/?p=4466 By Deborah B. Miller, Esq.

From a personal perspective, prenuptial agreements are not very appealing, but from a common sense and legal point of view, they can be essential. Getting married is the biggest financial decision in most people’s lives, but many do not consider the financial entanglements that marriage creates.  Just ask anyone who has lost a house or retirement plan in a divorce. Despite reading articles about the importance of using a prenuptial agreement as a tool for planning, plenty of people feel uncomfortable with prenuptial agreements.  Luckily, there are secondary measures, not all as good as a prenuptial agreement, but perhaps more in line with your personal views and the realities of your relationship.  For example, there are ways to structure corporate documents to insulate your medical practice from divorce proceedings, whether your own divorce or that of another physician in your practice.  Buy-sell agreements among shareholders and corporate insurance policies in the event of a forced buyout can be effective tools to protect the practice.  Likewise, postnuptial agreements are an option, even if the prenuptial agreement seemed awkward at the time of marriage.  A postnuptial agreement can be limited to a spouse relinquishing claims on your interest in your medical practice.  This can be a mandatory prerequisite for membership in a practice group, essentially forcing all group members to enter either prenuptial or postnuptial agreements to protect the medical practice from divorce.  This can be effective, as the pressure to enter such an agreement is external, and the blame for needing a postnuptial agreement can be shifted to the attorney for the medical practice.  It’s easy to blame the attorney, just give it a try. Everyone (whether married or not) should make sure their estate plans are up to date and there are a variety of situations in which prenuptial agreements should part of those estate plans.  The most important of these situations are a second marriage, or where at least one spouse has children before the marriage. Let’s start with what happens in a second marriage from a social perspective.  Statistics tell us that 2 out of 3 second marriages fail.  Yet hope springs eternal, as does love, and plenty of divorced folks get remarried.  Those who remarry are more experienced than the first time around, having learned either personally or through a friend the expense and stress associated with a difficult divorce.  Most people have heard about prenuptial agreements, but may not understand how a prenuptial agreement can help them avoid a long and costly divorce, while also protecting their Estate for their children.  Essentially, a prenuptial agreement should streamline a divorce in the event the marriage does not work out, having resolved the marital financial issues before the marriage.  The prenuptial agreement, however, will not address the issues as to any children of the marriage, such as child support and custody.  What it can do for you is to protect your medical practice, your salary, your pension and your retirement account.  It can state how the marital home is to be handled and what property is separate property.  The significance of protecting your medical practice from equitable distribution during a divorce, and your salary from years of alimony cannot be understated. A prenuptial agreement can set forth the financial parameters of the marriage from the day of the wedding up through and including how your Estate is handled after you die.  It can state whether your spouse has a right to an interest in your retirement benefits and your medical practice.  It can state whether or not your spouse waives the right to claim spousal support or alimony.  Some couples do not agree on a straightforward waiver of rights, but instead agree on a sliding scale—the longer the marriage lasts, the greater a dependent spouse’s entitlement to a portion of specified marital property. In addition to setting the financial parameters of your marital relationship, a prenuptial agreement is the best tool to prevent your Estate from ending up in the hands of someone else’s children.  Let’s consider Mom, who at 65 looks great (because she follows her family physician’s advice).  Last year, she married Bob.  Mom has a son and a daughter, but Mom did not get around to having a pre-nuptial agreement...so what happens when Mom dies before Bob and she does not have a will?  If Mom is a resident of Pennsylvania, we need to consider Bob’s statutory right of election.  This law allows, but does not require, Bob to “elect” to take 1/3 of Mom’s Estate.  The right of election exists whether or not Mom has a Will, and regardless of what Mom leaves Bob in her Will.  The only way to cancel this right is by agreement between Mom and Bob. If Bob elects against Mom’s will, he gets 1/3 of Mom’s assets that pass through her Will. Let’s say Mom’s Estate assets are a 0,000 investment account, and her house worth 0,000—a total of 0,000—essentially the money Dad made through hard work and careful saving.  This means that Bob gets 0,000, Mom’s son inherits 0,000, and Mom’s daughter inherits 0,000. Did Mom want Bob to get 0,000 from her Estate? Didn’t Mom always say she would leave everything to her children 50/50? A simple solution would have been a prenuptial agreement stating that Mom and Bob mutually waive their rights to each other’s Estates, including a waiver of their statutory right to claim an Elective Share.  Or, if there was no prenuptial agreement, a post-nuptial agreement is another option.  The agreement to waive the elective share need not occur before the marriage. In the event Mom does not want to leave Bob without anything, Mom and Bob can explore options that express loyalty and respect for her late husband and their children, as well as for Bob’s well-being after she dies.  For example, Mom may wish to grant Bob a life estate in her home, so long as he pays upkeep and taxes or may want to fund a testamentary trust from which Bob can obtain income and support after her death.  Depending on Mom’s wishes and the situation, this can be accomplished in a prenuptial agreement, a Will or by Deed. In second marriages, using Mom above as the ongoing example, there is a particular need to address where Mom will be buried.  If she does not make her intentions as to her remains firmly known, then Pennsylvania law allows Bob as the surviving spouse the unfettered right to decide where she will be buried.  Bob might want her to be buried in Florida near his winter condo.  Mom’s children, however, may want Mom to be buried next to Dad in the established family plot in Pennsylvania.  To resolve this issue, Mom can state her intentions as to her remains in her Will. There are plenty of other marital issues that can be addressed with other proper estate planning tools.  For example, a prenuptial agreement cannot protect Bob’s Estate from bills owed to third parties who provided Mom with “necessaries” such as a hospital care.  Nor can a prenuptial agreement protect Bob’s Estate from the Commonwealth of Pennsylvania seeking dollar-for-dollar reimbursement for all Medicaid benefits provided to Mom.  Depending on which issues are relevant to each couple, there are estate planning tools that can be used to address the various concerns, including placing monies in an irrevocable inter vivos trust. Second marriages involving younger couples are equally fraught with their own types of financial concerns that benefit from a prenuptial agreement.  In the case of younger couples who remarry with children from a prior marriage, the prenuptial agreement should address the thorny issues of how income and assets will be allocated to children and step-children for things ranging from medical expenses, to college tuition, to legal fees for custody and child support proceedings.   ###   Deborah B. Miller, Esquire, is a partner at Strong, Stevens, Miller & Wyant, P.C. (www.strongfirm.com). For follow up, please contact Debbie directly at (610) 239-8600 x 234 or dmiller@strongfirm.com  ]]> http://www.physiciansnews.com/2011/12/06/how-to-protect-your-practice-from-your-spouse/feed/ 0 Uncertainty Doesn’t Have to Mean Loss of Control for Physicians http://www.physiciansnews.com/2012/02/01/help-your-patients-get-the-benefits-they-deserve/ http://www.physiciansnews.com/2012/02/01/help-your-patients-get-the-benefits-they-deserve/#comments Wed, 01 Feb 2012 19:07:18 +0000 Physicians News http://www.physiciansnews.com/?p=4583 [/caption] By Eric A. Shore, J.D. and Pia Horton Everyday your patients trust you to care for their health. Many of your patients find themselves unemployed and therefore, uninsured. While some will find work eventually, those with physical and/or mental limitations may not. This is especially true for those approaching retirement age (50-65 years). You can help. Patients who are unable to sustain work due to their health may be eligible for Social Security disability benefits, therefore making them eligible for Medicare or Medicaid. Although treating your patients is obviously your primary concern, taking a few steps to encourage patients to apply and obtain Social Security benefits may be necessary for them to afford the care you provide. Physicians play an instrumental role in helping their patients obtain the Social Security disability benefits they need.  Social Security disability claims are evaluated by determining whether your patient suffers from a severe physical and/or mental impairment that has lasted and/or will last for twelve (12) months, and/or result in your patient's death.  Judges and attorneys review your medical records, looking for your specific documentation of your patient’s physical and mental limitations and how those limitations are caused by your patient's impairments.  To be most helpful, your medical records should also indicate how those limitations prevent or restrict your patient's ability to function on a daily basis. The severity and duration requirements can only be proven by obtaining proper medical evidence, as medical evidence is key to any successful Social Security Disability claim.  Social Security cases are often built and won on the strength of the medical records provided by a client’s treating physician.    Therefore, detailed progress/treatment notes, an accurate accounting of your patient's subjective complaints, referrals to specialists, and referrals for objective testing are necessary to build a winning claim. Your treatment notes are an important part of building the strength of your patient's case.  Consistent treatment should be documented with detailed narratives that include the following: specific dates of treatment, your diagnosis, the nature of your patient’s illness, its etiology, severity, and to what degree the impairment limits your patient’s ability to perform day to day activities, function on a job, and/or maintain full time employment. For example, if your patient has COPD and experiences severe dyspnea, chest pains, wheezing, and fatigue upon minimal exertion, indicate all in your treatment narratives.  Further indicate that medium and heavy exertional level activities are not recommended for your patient, and document specific functional restrictions and/or precautions that your patient should exercise on a daily basis.   Also, note why your patient should not partake in specific exertional activities.  For example, "due to Chronic Obstructive Pulmonary Disease, my patient’s lung volume capacity is severely compromised.  My patient should not lift any weight over ten (10) pounds frequently; never climb ladders; never walk for more than five (5) minutes; avoid vacuuming, dusting, mopping, and standing for more than thirty (30) minutes at a time; avoid all exposure  to dust, chemicals, or other environmental hazards."  Also indicate what adverse effects your patient will experience if he or she partakes in any of the restricted activity Your patient’s subjective complaints are extremely important to record upon every visit to your office.  Often, subjective complaints suggest the true severity of your patient’s impairment and how the impairment limits his or her ability to function.  Subjective complaints of chronic and severe pain should prompt further objective testing, physical therapy, and/or referrals to specialists. The results of objective tests offer concrete evidence that cannot be disputed.  Making timely and accurate referrals for CT scans, MRI’s, and X-rays can strengthen your patient’s case and provide and further confirm your diagnosis.  In addition, timely referrals to specialists and physical therapists document the severity of your patient’s impairment and can significantly increase the chances of winning the claim by indicating your patient’s need for ongoing care and treatment.  With the proper referrals, your patient can build a well documented treatment history, which will in turn bolster your patient’s credibility and increase his or her chances of success.  Moreover, timely objective testing can show permanent impairments, helping to satisfy both the severity requirement and the twelve (12) month duration requirement.  For example, frequently a patient who suffers from severe asthma and/or airway restriction disease is referred for a  Pulmonary Function Testing (PFT).  The results of an initial PFT may only show a mild impairment.  However, over the course of time, your patient's complaints and symptoms may worsen requiring you to refer them for further testing.  Subsequent tests can document how your patient's illness has progressed from tolerable to disabling. Often times, physicians note that their patient is applying for disability benefits, but do not indicate whether they have observed whether their patient is disabled.  Therefore, your observations of how your patient’s impairments affect them should be documented, as well. For example, noting that your patient walks with a limp, experiences frequent falls, has difficulty getting on or off of your examining table, was short of breath walking a short distance, heard voices, could not focus during your exam, could not walk from the waiting room to the treatment room without assistance, winces in pain to your touch, or requires assistive devices to ambulate, can benefit your patient’s claim. When your observations are consistent with your patient's subjective complaints and objective test results, the strength of your patient's claim increases substantially. Moreover, completing simple questionnaires or residual functional capacity (RFC) forms indicating how your patient’s impairments limit their ability to function can be invaluable to your patient’s claim.  Residual Functioning Capacity (RFC) forms and/or Medical Source Statement (MSS) are of great importance to any Social Security disability claim.  The forms help Social Security to evaluate the functional limitations caused by your patient's impairments by giving us insight into how those impairments limit the ability to perform work related activities.  The form consists of a list of physical or mental activities allowing the treating physician to assess their patient's ability to perform work related activities by indicating how the patient’s ability to function is limited by his or her impairment.  More importantly, the form contains sections that allow you to further comment on your patient's limitations in a brief narrative.  In a sense, the form gives you an opportunity to be present at your patients hearing. A supported RFC form completed by you may be the most influential piece of evidence in the case and may actually determine whether your patient will receive the benefits they need.  We know completing forms and copying records for legal matters are not a primary concern. However, because your assistance can be the deciding factor in whether your patient will obtain Medicare/Medicaid and the cash benefits needed to afford transportation to your office, helping patients with their Social Security disability and SSI cases is different. The Social Security Administration must consider all medical evidence of record in your patient's claim including your records and opinions, and give great weight to all evidence submitted by you, the treating physician.  Therefore, your observations, recommendations, referrals, and treatment plans are crucial in assessing your patient’s case and achieving the favorable outcome your patient needs and deserves. ### The Law Offices of Eric A. Shore, P.C. (www.1800cantwork.com) focuses on matters of Social Security Disability and SSI benefits.  They can be reached at 215.627.9999.    ]]> http://www.physiciansnews.com/2012/02/01/help-your-patients-get-the-benefits-they-deserve/feed/ 1 Physicians News » Featured http://www.physiciansnews.com Tue, 07 Feb 2012 16:44:06 +0000 en hourly 1 http://wordpress.org/?v=3.2.1 Help Your Patients Get the Benefits They Deserve http://www.physiciansnews.com/2012/02/01/help-your-patients-get-the-benefits-they-deserve/ http://www.physiciansnews.com/2012/02/01/help-your-patients-get-the-benefits-they-deserve/#comments Wed, 01 Feb 2012 19:07:18 +0000 Physicians News http://www.physiciansnews.com/?p=4583 [/caption] By Eric A. Shore, J.D. and Pia Horton Everyday your patients trust you to care for their health. Many of your patients find themselves unemployed and therefore, uninsured. While some will find work eventually, those with physical and/or mental limitations may not. This is especially true for those approaching retirement age (50-65 years). You can help. Patients who are unable to sustain work due to their health may be eligible for Social Security disability benefits, therefore making them eligible for Medicare or Medicaid. Although treating your patients is obviously your primary concern, taking a few steps to encourage patients to apply and obtain Social Security benefits may be necessary for them to afford the care you provide. Physicians play an instrumental role in helping their patients obtain the Social Security disability benefits they need.  Social Security disability claims are evaluated by determining whether your patient suffers from a severe physical and/or mental impairment that has lasted and/or will last for twelve (12) months, and/or result in your patient's death.  Judges and attorneys review your medical records, looking for your specific documentation of your patient’s physical and mental limitations and how those limitations are caused by your patient's impairments.  To be most helpful, your medical records should also indicate how those limitations prevent or restrict your patient's ability to function on a daily basis. The severity and duration requirements can only be proven by obtaining proper medical evidence, as medical evidence is key to any successful Social Security Disability claim.  Social Security cases are often built and won on the strength of the medical records provided by a client’s treating physician.    Therefore, detailed progress/treatment notes, an accurate accounting of your patient's subjective complaints, referrals to specialists, and referrals for objective testing are necessary to build a winning claim. Your treatment notes are an important part of building the strength of your patient's case.  Consistent treatment should be documented with detailed narratives that include the following: specific dates of treatment, your diagnosis, the nature of your patient’s illness, its etiology, severity, and to what degree the impairment limits your patient’s ability to perform day to day activities, function on a job, and/or maintain full time employment. For example, if your patient has COPD and experiences severe dyspnea, chest pains, wheezing, and fatigue upon minimal exertion, indicate all in your treatment narratives.  Further indicate that medium and heavy exertional level activities are not recommended for your patient, and document specific functional restrictions and/or precautions that your patient should exercise on a daily basis.   Also, note why your patient should not partake in specific exertional activities.  For example, "due to Chronic Obstructive Pulmonary Disease, my patient’s lung volume capacity is severely compromised.  My patient should not lift any weight over ten (10) pounds frequently; never climb ladders; never walk for more than five (5) minutes; avoid vacuuming, dusting, mopping, and standing for more than thirty (30) minutes at a time; avoid all exposure  to dust, chemicals, or other environmental hazards."  Also indicate what adverse effects your patient will experience if he or she partakes in any of the restricted activity Your patient’s subjective complaints are extremely important to record upon every visit to your office.  Often, subjective complaints suggest the true severity of your patient’s impairment and how the impairment limits his or her ability to function.  Subjective complaints of chronic and severe pain should prompt further objective testing, physical therapy, and/or referrals to specialists. The results of objective tests offer concrete evidence that cannot be disputed.  Making timely and accurate referrals for CT scans, MRI’s, and X-rays can strengthen your patient’s case and provide and further confirm your diagnosis.  In addition, timely referrals to specialists and physical therapists document the severity of your patient’s impairment and can significantly increase the chances of winning the claim by indicating your patient’s need for ongoing care and treatment.  With the proper referrals, your patient can build a well documented treatment history, which will in turn bolster your patient’s credibility and increase his or her chances of success.  Moreover, timely objective testing can show permanent impairments, helping to satisfy both the severity requirement and the twelve (12) month duration requirement.  For example, frequently a patient who suffers from severe asthma and/or airway restriction disease is referred for a  Pulmonary Function Testing (PFT).  The results of an initial PFT may only show a mild impairment.  However, over the course of time, your patient's complaints and symptoms may worsen requiring you to refer them for further testing.  Subsequent tests can document how your patient's illness has progressed from tolerable to disabling. Often times, physicians note that their patient is applying for disability benefits, but do not indicate whether they have observed whether their patient is disabled.  Therefore, your observations of how your patient’s impairments affect them should be documented, as well. For example, noting that your patient walks with a limp, experiences frequent falls, has difficulty getting on or off of your examining table, was short of breath walking a short distance, heard voices, could not focus during your exam, could not walk from the waiting room to the treatment room without assistance, winces in pain to your touch, or requires assistive devices to ambulate, can benefit your patient’s claim. When your observations are consistent with your patient's subjective complaints and objective test results, the strength of your patient's claim increases substantially. Moreover, completing simple questionnaires or residual functional capacity (RFC) forms indicating how your patient’s impairments limit their ability to function can be invaluable to your patient’s claim.  Residual Functioning Capacity (RFC) forms and/or Medical Source Statement (MSS) are of great importance to any Social Security disability claim.  The forms help Social Security to evaluate the functional limitations caused by your patient's impairments by giving us insight into how those impairments limit the ability to perform work related activities.  The form consists of a list of physical or mental activities allowing the treating physician to assess their patient's ability to perform work related activities by indicating how the patient’s ability to function is limited by his or her impairment.  More importantly, the form contains sections that allow you to further comment on your patient's limitations in a brief narrative.  In a sense, the form gives you an opportunity to be present at your patients hearing. A supported RFC form completed by you may be the most influential piece of evidence in the case and may actually determine whether your patient will receive the benefits they need.  We know completing forms and copying records for legal matters are not a primary concern. However, because your assistance can be the deciding factor in whether your patient will obtain Medicare/Medicaid and the cash benefits needed to afford transportation to your office, helping patients with their Social Security disability and SSI cases is different. The Social Security Administration must consider all medical evidence of record in your patient's claim including your records and opinions, and give great weight to all evidence submitted by you, the treating physician.  Therefore, your observations, recommendations, referrals, and treatment plans are crucial in assessing your patient’s case and achieving the favorable outcome your patient needs and deserves. ### The Law Offices of Eric A. Shore, P.C. (www.1800cantwork.com) focuses on matters of Social Security Disability and SSI benefits.  They can be reached at 215.627.9999.    ]]> http://www.physiciansnews.com/2012/02/01/help-your-patients-get-the-benefits-they-deserve/feed/ 1 Practical Implications of Telemedicine Credentialing http://www.physiciansnews.com/2012/01/30/practical-implications-of-telemedicine-credentialing/ http://www.physiciansnews.com/2012/01/30/practical-implications-of-telemedicine-credentialing/#comments Mon, 30 Jan 2012 20:03:46 +0000 Physicians News http://www.physiciansnews.com/?p=4569 By Lucia Francesca Bruno, J.D., LL.M., M.B.A. For the past century, information technology has reinvented the familiar and revolutionized the art of medicine.  As health care professionals struggle to keep pace with an ever-changing and consolidating industry, traditional forms of health care have succumbed to modern technology and fiscal constraints.  No longer are patients and providers afforded the luxury of being in the same place at the same time.  Recent developments in patient-service delivery systems have transformed the doctor/patient relationship; paving the way for advances in telemedicine and the credentialing and privileging of telemedicine practitioners.  Inside Look into Telemedicine The Centers for Medicare and Medicaid (“CMS”) defines telemedicine as “the provision of clinical services to patients from a distance via electronic communications.”[1] Although telemedicine is not considered a medical specialty, products and services unique to this practice of medicine often require a costly investment in information technology and the delivery of clinical care by health care providers. Telemedicine seeks to improve a patient’s health by permitting two-way, interactive, communication between the patient and the physician, at a distant-site, for purposes of assessment, diagnosis, and intervention.  Examples of telemedicine include, but are not limited, to the following:  videoconferencing; transmission of still images, and remote monitoring of vital signs. A Past Marred by Obstacles Historically, smaller hospitals and Critical Access Hospitals (“CAHs”) desiring to take advantage of this cost-effective form of clinical care were hampered by duplicative and burdensome Conditions of Participation (“CoPs”) and redundant regulations.   In particular, the credentialing process of obtaining and reviewing practitioner data such as licensure, training, certifications, insurance, and National Practitioner Data Bank queries created a financial burden many hospitals simply could not afford.   Furthermore, many lacked the clinical expertise within their medical staff to evaluate and grant privileges to physicians providing telemedicine services. In a notorious policy brief issued by the National Rural Health Association (“NRHA”) in 2010, providers maintained that “the current telehealth credentialing process was more than an annoyance; it was a deterrent for providers and hospitals, and a barrier to expanding health care access.”[2]  NRHA urged CMS to “adopt a policy that allowed telemedicine providers to receive deemed status (as having met Medicare/Medicaid certification requirements) and permit health care facilities receiving telehealth services to perform credentialing by proxy (delegated credentialing).”[3]  NRHA surmised that “if a provider was already credentialed at a Medicare-participating facility, that credential would be sufficient to provide telemedicine services at another facility; while, the privileging process would remain the responsibility of the originating health care facility.”[4] A Future Swayed by Reason Acknowledging the need for transformational change, on May 5, 2011, CMS introduced the final rule which superseded prior Joint Commission privileging recommendations, and considerably streamlined the credentialing and privileging process for physicians providing telemedicine services. [5] The final rule, effective July 5, 2011, made Federal requirements more flexible and encouraged innovative approaches to the delivery of patient-services; thereby, allowing patients to receive medically necessary interventions in a timelier manner.[6]   In addition to taking a more lenient approach to CoPs, CMS expanded the platform of telemedicine by defining key terms and requiring a written agreement between the "patient-site" and the "distant-site."   The written agreement, subject to disclosure to CMS, must include specific elements and evidence the telemedicine practitioner’s privileges at the “distant-site.” Key Terms Defined by CMS “Telemedicine” is defined as “the provision of clinical services to hospital or CAH patients by practitioners from a distance via electronic communications, either simultaneously or non-simultaneously.”[7] “Simultaneous” telemedicine services are performed in real-time, similar to the actions of an on-site practitioner when called in by an attending physician to see a patient, e.g., teleICU services. [8] “Non-simultaneous” services are clinical services provided to the patient upon a formal request from the patient’s attending physician or practitioner; such services may involve after-the-fact interpretation of diagnostic tests and do not necessarily require the telemedicine practitioner to directly assess the patient in real-time, e.g., teleradiology services.[9] “Distant-site” the location at which the physician or other licensed practitioner delivering the service is located at the time the service is provided via telecommunications.  A “distant-site” is either a Medicare-participating hospital or telemedicine entity (non-Medicare participating hospital) that provides contracted telemedicine services in a manner that enables the hospital or CAH using telemedicine services to meet all applicable CoPs; particularly, those related to the credentialing and privileging of telemedicine practitioners. [10] Written Agreement Required:  Distant-Site Hospital When the distant-site is a Medicare-certified hospital, the final rule requires that the hospital or CAH have a written agreement that expressly states that it is the responsibility of the distant-site hospital to meet the credentialing requirements of 42 C.F.R. 482.12(a)(1)-(a)(7) for hospitals or 42 C.F.R. 485.616(c)(i)-(c)(vii) for CAHs.  In addition, the written agreement must contain the following: (i) the distant-site hospital is a Medicare-participating hospital; (ii) the distant-site practitioner is privileged at the distant-site hospital as evidenced by a current list of the practitioner’s privileges provided by the distant-site hospital; (iii) the practitioner holds a license issued and/or recognized by the state in which the hospital or CAH whose patients receive telemedicine services is located; and (iv) the hospital that credentials and privileges the distant-site practitioner disclose the practitioner’s performance information, e.g., adverse events, complaints, and internal reviews. Written Agreement Required:  Distant-Site Telemedicine Entity To rely on the credentialing and privileging decisions by a distant-site telemedicine entity, the distant-site must affirm, in writing, that the telemedicine entity is a contactor of services to the hospital and furnishes contracted services in a manner that permits the hospital to comply with all applicable CoPs, 42 C.F.R. 482.12(a)(1)-(a)(7) for hospitals or 42 C.F.R. 485.616(c)(i)-(c)(vii) for CAHs.  In addition, the written agreement must contain the following: (i) the distant site’s credentialing and privileging process at least meet the standards in 42 C.F.R. 482.12(a)(1)-(a)(7) and 42 C.F.R. 482.22(a)(1)-(a)(2) when the originating-site is a hospital or 42 C.F.R. 485.616(c)(1)(i)-(c)(1)(vii) when the originating-site is a CAH; (ii) the distant-site practitioner has the experience and expertise as represented by the distant-site telemedicine entity; (iii) the practitioner holds a license issued and/or recognized by the state in which the hospital or CAH is located; and (iv) the hospital or CAH has evidence of an internal review of the distant-site practitioner’s performance of privileges to be exercised at the hospital or CAH; conversely, the hospital or CAH  must send the distant-site entity performance information for use in the entity’s periodic appraisal of the distant-site practitioner. Effect on State Licensure Despite the sweeping reform brought about by the final rule, CMS cautioned that all state-based physician licensure requirements will remain unchanged. Recognizing the fact that “licensure laws and regulations have traditionally been, and continue to be, the provenance of individual States, the final rule does not pre-empt State authority.”[11] Although states remain split on the issue of telemedicine, many states espouse that their existing laws adequately reflect their position on the licensure of telemedicine practitioners.  Other states, however, affirm that a full and unrestricted license is necessary to practice telemedicine, and have reinforced that stance in law or policy.[12] In an effort to address growing concerns amongst medical professionals, the American Medical Association (“AMA”) reaffirmed its policy to support state-based licensure for physicians and oppose national licensure approaches to telemedicine. In its annual assessment of physician licensure, the AMA declared that “telemedicine in particular has crystallized the tension between the states’ role in protecting patients from incompetent physicians and protecting in-state physicians from out-of-state competition, and the desirability of ensuring patients’ access to the highest quality medical advice and treatment possible, wherever located.” [13] Despite tension between the states’ power to regulate health care professionals and the prohibition against restraint on interstate commerce, the practice of telemedicine has yet to be addressed by the courts.  Only time will tell if the final rule is sufficient to spur litigation in this cutting-edge practice of medicine. Informed Consent Considerations Despite comments to CMS encouraging patient informed consent be obtained before the use of telemedicine services by a hospital or CAH, CMS affirmed that under the final rule “there is no difference between distant-site practitioners and in-house or on-site practitioners with respect to informed consent.”[14]  CMS reiterated that “as long as the telemedicine practitioner is performing his or her duties within the privileges granted by the hospital or CAH, in accordance to a policy that requires informed consent, then consent must be obtained regardless of whether treatment is furnished by telemedicine or not.”[15]  For providers, this insightful decision alleviated one more instance of costly red tape.  Medical Staff Bylaws and Standard Operating Procedures In order to ensure full compliance and avoid unnecessary complications, providers are encouraged to amend medical staff bylaws and revise policies and procedures related to credentialing and privileging.  In particular, medical staff bylaws should contain current definitions relevant to telemedicine and an accurate description of the information-sharing process.  Medical staff bylaws should also reflect administrative changes to the provider’s Credentials Committee and Medical Executive Committee, especially as it pertains to clinical services provided by telemedicine. Furthermore, medical staff policies and procedures should be amended to account for changes in clinical protocols, insurance coverage, billing and reimbursement, and HIPAA compliance.   As a precautionary measure, any medical staff policies that require the “physical presence” of a physician should be reevaluated to account for the delivery of patient services by electronic communications. Finally, under the final rule, hospitals and CAHs that take advantage of privileging by proxy must disclose privileged peer review information to the distant-site.  Therefore, it is advisable that hospitals and CAHs carefully assess state-specific peer review guidelines and include language in the written agreement that ensures ongoing protection of peer review information. Conclusion There is no doubt that sweeping changes in the credentialing and privileging process has paved the way for greater advances in telemedicine services.   Dale Alverson, M.D., past president of the American Telemedicine Association surmised that “the final rule will truly help patients receive the care they need, no matter where they live or where their doctor is located.”[16] By eliminating the overly burdensome credentialing and privileging rules in Medicare, Dr. Alverson concluded that “CMS has shown growing support of telemedicine.” [17] Despite the obvious benefits to patients, the long-term ramifications of the final rule on providers are yet, unknown.  Hospitals and CAHs using telemedicine services of distant-site practitioners are, therefore, encouraged to implement adequate policies and procedures to protect their interests and those of their patients. ### Lucia Francesca Bruno, J.D., LL.M., M.B.A., is Principal Shareholder of Physicians’ Legal Group, LLC (www.physicianslegalgroup.com). She can be reached at Lbruno@physicianslegalgroup.com.  

[1] Medicare and Medicaid Programs: Changes Affecting Hospitals and Critical Access Hospital Conditions of Participation: Telemedicine Credentialing and Privileging, 76 Fed. Reg. 25, 551 (May 5, 2011).
[2] Lewis, Pam, Mandy Bell, BA,  Deanna Larson, RN, BSN, and  Jay Weems, MBA:  “Telehealth Provider Credentialing” National Rural Health Association Policy Brief (2010): 1-4.
[3] Lewis, Bell, Larson, Weems, Telehealth Provider Credentialing, 1.
[4] Id. at 1
[5]  Medicare and Medicaid Programs: Changes Affecting Hospitals and Critical Access Hospital Conditions of Participation: Telemedicine   Credentialing and Privileging, 76 Fed. Reg. 25,550, 25,551 (May 5, 2011).
[6] 76 Fed. Reg.  25,551.
[7] Id. at 551.
[8] Id.
[9] Id.
[10] Section 1834(m)(4)(A) of the Social Security Act
[11] 76 Fed. Reg.  25,557.
[12] Office for the Advancement of Telemedicine, “Telemedicine Licensure Report” (2003).
[13] American Medical Association, “Physician Licensure: An Update of Trends” American Medical Association, 2012. Web. 15 January 2012 http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/young-physicians-section/advocacy-resources/physician-licensure-an-update-trends.page.
[14] 76 Fed. Reg.  25,555.
[15] Id. at 255.
[16] http://learntelehealth.org/blog/post/final-ruling-on-credentialing-privileging-of-telehealth-providers/
[17] Id.
]]> http://www.physiciansnews.com/2012/01/30/practical-implications-of-telemedicine-credentialing/feed/ 0 Health Care Reform Debate: More Thought and Less Volume, Please http://www.physiciansnews.com/2012/01/26/health-care-reform-debate-more-thought-and-less-volume-please/ http://www.physiciansnews.com/2012/01/26/health-care-reform-debate-more-thought-and-less-volume-please/#comments Thu, 26 Jan 2012 15:58:22 +0000 Physicians News http://www.physiciansnews.com/?p=4556 By Erika Stewart Health care reform will make huge changes in the way insurance companies do business, but most of that will not go into effect right away. Provisions that will help most Americans in 2012 affect policies that were purchased after March 13, 2010. Under the new laws, health insurance companies cannot:
  • Refuse to cover children under age 19 who have a pre-existing condition
  • Impose a lifetime limit
  • Cancel a policy unless they can prove fraudulent information was given
  • Fail to provide an appeal process for denied claims
New insurance policies must now include reasonable preventive services that carry no copayment or deductible. This includes usual vaccinations, cancer screenings, well-child office visits, blood pressure checks, and tests for such chronic conditions as diabetes and high cholesterol. Children without insurance who have not reached the age of 26 can now be carried on their parents' insurance, even if they are married and no longer live with their parents. Newer health plans must allow the patient to choose a primary care physician and cannot require a referral for an OB/GYN service. The law also prohibits companies from requiring patients to go to a particular emergency room or get prior authorization for emergency care. Effects on Physicians While all this is good news for American families, what about the effect on doctors? Why was the bill endorsed by both the American Medical Association and the American Hospital Association? Primary care physicians will receive more pay from government-sponsored insurance such as Medicare for encouraging patients to take advantage of preventive and outpatient services likely to lower the overall cost of care for individuals. They will also receive incentives for providing coordinated care, and for using electronic health records so that patients are better understood. Hospitals will benefit from reducing the number of charity cases without any payment. By 2014 Americans will receive subsidies to help those with lower income afford medical insurance. Starting in 2014, Medicaid will cover most people who have less than 133 percent of poverty level income. This is projected to bring an additional 16 million people into that system. The impact on states will vary, depending on how generous the Medicaid program is there. The Federal government will cover the cost until 2020 but will then ask states to shoulder more of the burden. With many politicians eyeing cuts to Medicaid in order to bring the budget under control, the poorest of American citizens may be in jeopardy of losing some of their medical care. President Obama has promised to cut 0 billion. House Republicans, led by Paul Ryan, are pushing to change Medicaid to a block grant program and repeal the expansion of coverage. Sustainable Growth Rate (SGR) Another interesting aspect of our health care law is Medicare’s Sustainable Growth Rate (SGR). SGR is defined as the fastest rate at which an organization can grow without collapsing. This figure is used to adjust the Medicare fee schedule so that the fund does not become depleted. If expenditures exceed the SGR, the fee schedule is adjusted downward. However, the formula used does not take into account the increasing volume and complexity of care. A true reflection of program costs must take these factors into consideration. Some critics have complained that the health care reform law does not address this issue. That was not the focus of the bill, which deals mainly with issues of insurance coverage. As the debate about health care reform continues, doctors have weighed in both in favor of the law and concerned about its implications. On her blog “Barking Doc,” Maggie Kozel MD presents her perspective. She says, among other astute comments, that the discussion needs to focus on stewardship. As citizens of this wealthy nation, what is our responsibility? Dr. Kozel is author of “The Color of the Atmosphere: One Doctor’s Journey In and Out of Medicine.” After 10 year’s of practice in Navy medicine, Kozel entered private practice where she was confronted with the inequities of the current system and what that means in terms of patient care. Speaking of the relationship between doctor and patient, she writes, “conversation between doctor and patient is the most undervalued commodity in our health insurance system.” Whether the new law will survive attacks by conservatives, and how well it will address the needed changes in our health care system, remain to be seen. Thoughtful debate on the serious issues involved instead of bickering backed by special interests would help both Congress and the President focus on positive change. As Dr. Kozel writes, what is needed is more thought and less volume.                  ]]> http://www.physiciansnews.com/2012/01/26/health-care-reform-debate-more-thought-and-less-volume-please/feed/ 2 Camden Coalition’s Model for High Needs Patients http://www.physiciansnews.com/2012/01/09/camden-coalition%e2%80%99s-model-for-high-needs-patients/ http://www.physiciansnews.com/2012/01/09/camden-coalition%e2%80%99s-model-for-high-needs-patients/#comments Mon, 09 Jan 2012 15:33:37 +0000 Physicians News http://www.physiciansnews.com/?p=4529 By Jen Abraczinskas and Jeffrey Brenner, MD [caption id="attachment_4531" align="alignleft" width="100" caption="Jen Abraczinskas"][/caption] There is a lot of buzz about reducing hospital readmissions.  But what does a readmission look like?  And what will it take to provide the care needed to avoid readmissions? We arrived at the ICU to find our patient sedated and intubated. Yet only 10 days earlier Mrs. P was strong enough to navigate the halls in her wheel chair, had her diabetes and COPD under control and was taking her medications for bipolar disorder. Mrs. P was discharged with an abundance of home health services – nursing, physical therapy, occupational therapy, home health aid.  How had her condition declined so quickly?  We visited her on day three post-discharge.  Mrs. P was in her living room hospital bed covered in her own body fluids unable to turn herself.  We helped her husband clean her, dress her, and move her into a position where her lungs had a chance to fully expand.  We also checked her blood sugar – slightly over 250.  The rehab center had discharged her with sliding scale insulin and believed that her elderly husband knew how to administer it.  However, when we asked him to try, he only pulled up air into the syringe.  He was not strong enough or organized enough to take care of Mrs. P’s incredibly demanding health needs which required over 10 medications, multiple monthly doctors visits, special transportation, and help with daily living activities.  A 4-day lag in her home health agency opening her case was enough time for Mrs. P’s health status to go from good to seriously troubled. [caption id="attachment_4532" align="alignleft" width="96" caption="Jeffrey Brenner"][/caption] Mrs. P’s experience wasn’t a new one.  The ICU stay was her third admission to the hospital in the last three months.  Initially she had been hospitalized for a COPD exacerbation, sent to rehab, discharged home for several hours before a decline that required another hospital admission and then she repeated this cycle. She was frustrated. Her family was frustrated. And we were frustrated as we watched her careen between the best healthcare Camden has to offer and near neglect of her health needs.  The reasons for the cycle are complex with her greatest complication being our fragmented health system.  During her hospital and rehab stays her health improved because she was receiving daily assistance with her complicated medication regime. Following discharge her inability to use her glucometer, administer insulin, and understand her medications left her vulnerable to rapid health decline.  Since her admissions began, she had been disconnected from primary care and getting her into a new primary care doctor would take weeks.  As her husband battled his own health problems, she needed more assistance at home but did not qualify because her Medicaid application is only just started. Mrs. P’s suffering is also costly. During the last three months, Medicare paid over ,000 for Mrs. P’s 3 admissions, including 2 ICU stays, and 11 weeks of rehab.  Preventing her third readmission alone would have saved Medicare ,482.  Then there is the cost to Mrs. P and her family.  She kept losing the good health she would gain in rehab.  Her husband felt guilty and embarrassed that he could not provide the expert care his wife needed to stop cycling in and out of the hospital.   Sadly, Mrs. P. is not alone in her struggles to stay healthy and out of the hospital.  Everyday in the United States, 10,000 more people turn 65 and many will suffer with multiple chronic illnesses, trouble with transportation, and questions regarding what level of care they truly need.  This population will bill Medicare with its expenses and overburden families with its home health needs. To break the hospitalization cycle and to curb healthcare spending, the Camden Coalition of Healthcare Providers has developed an innovative care management model for high needs / high costs patients in Camden NJ.  The Care Management Team relies on home visits with patients to coordinate doctors’ appointments, transportation, and social services.  The Team provides holistic medical care as well as root cause analysis and solutions to the often intertwined issue of poverty and disease that plague its patients. At any given time the Team sees approximately 35-40 patients. We are often asked why we work so intensely on a hand-full of patients.  From analyzing data gathered from three hospitals in Camden, we found that 1 percent of patients account for 30 percent of costs.  If we focus on the heaviest utilizers of health care, connect them into primary care, and address their needs outside of hospitals, we can begin to bend the cost curve.  The numbers are convincing and inform our overarching mission. But every day we also see the faces of patients needing assistance.  It is our patients’ confrontation with or neglect from our fragmented, difficult to navigate healthcare system that fuels the change we are trying to make. The Care Management Team has seen great success with many patients.  For Mrs. P., we ensured home health arrived soon after her discharge from this ICU stay and continued to communicate with them.  We connected her to a new primary care doctor and arranged transportation to her appointments. We involved her family in a discussion about long term goals and are facilitating her entry into an adult day program.  For other patients, we’ve supported them to achieve permanent housing, affordable medications, and primary and specialty care appointments with doctors who they trust.  Yet, we realize that time-intensive care management often falls into the laps of ill-equipped, overburdened primary care providers, hospital residents or insurance companies.  The Coalition is working to supply providers with tools to reduce the time and cost associated with great care coordination.  The Coalition has developed the Camden Health Information Exchange (HIE) to coordinate the hospital discharge summaries, lab data, and radiology reports for Camden residents.  The Camden HIE allows providers to have up-to-date information on their patients’ conditions and eliminates the need to order repeat tests.  We also are positioning Care Coordination Teams in Camden primary care offices.  The Teams will focus on patients with diabetes or high health care utilization for whom extra care coordination support is needed. As we look to the future, working in a more coordinated fashion is the only way that the needs of our growing, aging population will be met in the United States.  In Camden, we are testing models to improve health care and social services navigation, reduce unnecessary utilization, and equip providers with health information and coordination teams.  If we can support patients in their efforts to attain good health, we will decrease costs and be able to provide more and higher quality services for all. ### The Camden Coalition of Healthcare Providers (www.camdenhealth.org) was created with the overarching mission to improve the health status of all Camden, NJ residents, by increasing the capacity, quality, and access of care in the city.   Jen Abraczinskas is a third year medical student at the University of Pennsylvania and is spending a year with the Coalition as an Americorp volunteer.  Jen is a health coach with the Coalition's high utilizer project. Jeffrey Brenner, MD, is Director, Institute for Urban Health at Cooper University Hospital and Executive Director, Camden Coalition of Healthcare Providers. Naomi Wyatt, the Coalition's Director of Legal and Governmental Affairs, contributed to this article.]]> http://www.physiciansnews.com/2012/01/09/camden-coalition%e2%80%99s-model-for-high-needs-patients/feed/ 1 A Challenging Road Ahead for America’s Physicians http://www.physiciansnews.com/2012/01/05/a-challenging-road-ahead-for-america%e2%80%99s-physicians/ http://www.physiciansnews.com/2012/01/05/a-challenging-road-ahead-for-america%e2%80%99s-physicians/#comments Thu, 05 Jan 2012 15:20:33 +0000 Physicians News http://www.physiciansnews.com/?p=4508 By  Louis J. Goodman and Timothy B. Norbeck  This year promises to be a watershed year for healthcare in general, and for patients and physicians, in particular.  No matter how the U.S. Supreme Court determines the constitutionality of the Patient Protection and Affordable Care Act (PPACA), 2012 will be a crucial turning point in the delivery of healthcare. [caption id="attachment_4511" align="alignleft" width="150" caption="Louis J. Goodman, Ph.D."][/caption] During the Congressional passage of the PPACA, White House advisors acknowledged that the economic forces in the legislation would accelerate physician employment by hospitals and larger physician groups.  As mentioned in the “Roadmap for Physicians to Health Care Reform,” the “private” part of private practice for physicians is disappearing.  Currently, more than 80 percent of visits to physician offices have been to practices with five or fewer physicians.  That will change drastically as more physicians feel pressure to move into larger groups or become employed by hospital systems.  Through October of 2011, there have been 71 hospital mergers. All of this will change the face of the delivery aspect of health care, but a question remains: will it be for the better or worse? Expert opinion is almost universal that there is a present shortage of physicians, especially those in primary care and those practicing in rural areas.  This is a workforce problem that must be addressed now, but it seems to be lost in the debate over the PPACA.  The Physicians Foundation recognizes the shortage problem and recently awarded a large grant to The Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill to develop a dynamic web-based projection model that can be continually updated to track ongoing physician workforce needs across the country.  Information gleaned from the UNC research will further enhance efforts to identify where physicians are most needed to support patients in a growing healthcare system.  Thirty-six percent of practicing physicians are over age 55 and may retire by 2020.  According to Physician Foundation surveys conducted by Merritt Hawkins in 2008 and 2010, fewer physicians are seeing Medicare patients or taking on new Medicare patients.  With 10,000 baby boomers becoming eligible for Medicare every single day, the survey results do not bode well for access to care for Medicare patients. [caption id="attachment_4512" align="alignleft" width="150" caption="Timothy B. Norbeck"][/caption] Why do we have fewer physicians seeing Medicare patients at the very time that we need more of them?  First of all, the Sustainable Growth Rate (SGR) used to pay physicians under Medicare, singles out physicians for financial punishment in the form of payment reductions when volume of service increases.  With an aging population and increasing numbers of chronically ill elderly people, of course the volume of services continues to rise.  However, unless Congress steps in and acts promptly, Medicare physician payments are scheduled for an average reduction of 27.4 percent effective January 1, 2012.  The Physicians Foundation joins all other medical associations and the AARP in warning of the dire consequences on patients’ access to care should this massive and unwarranted reduction go through.  The fatally flawed SGR must be fixed and the aforementioned 27.4 percent scheduled reduction must be stopped. Much has been said about the PPACA, some good and some bad.  We would like to address the legislation from a physician’s point of view.  Physicians are extremely happy to have the American public insured and are delighted to have an end to the discrimination against their patients with pre-existing conditions. They also applaud the new focus on preventive care which should help lead to a healthier public.  As for the downside to the legislation, there was no SGR fix and no tort reform.  The PPACA also assumes a planned 30 percent reduction in physician fees scheduled under the SGR over the next three years.  Furthermore, and this is something that is largely overlooked when discussing the legislation, any physician’s office which mistakenly and by mere accident improperly bills too much for a Medicare visit, is subject to potential liability under federal fraud and abuse statutes. Before the PPACA, intent to commit fraud was necessary for a charge of fraud to be made, but now even an innocent error can result in prosecution.  Finally, and also overlooked by many, is the “translation” fee which must be paid by the treating physician.  If a physician treats a patient who doesn’t speak English and requires a translator, the physician is responsible for the translation fee.  In other words, the translator’s bill would probably exceed the physician’s reimbursement for the office visit! These issues and other pressures on physicians help explain some of the survey results from the 2010 Physicians Foundation Health Reform Research Study, and the numbers only become bleaker when comparing the results from our 2008 survey.  Only one-quarter of physicians surveyed said they plan to continue practicing as they are; while half reported that they would adopt a style of practice different from the traditional full-time independent private practice model.  Hence, the “private” in private practice is going, going, gone! Clearly, increasing administrative burdens attributable to the PPACA requirements plus insurance, red tape and costly regulatory measures are having a likely negative effect on patient care.  Sixty-three percent of physicians surveyed claimed that non-clinical paperwork has caused them to spend less time with their patients and 94 percent said that the time they devote to non-clinical paperwork has increased over the past three years.  Ask any physician what he or she enjoys the most about practicing medicine and the response will be: “seeing, helping and interacting with my patients.” The increasing amount of regulations and paperwork are becoming a more formidable barrier to the joy of practicing medicine.  Add to that the declining reimbursements and difficulty in sustaining one’s practice, the constant threat of liability, decreased time with patients and low or no bargaining power with insurers, it is not surprising to note that general physician morale is low and getting lower. A recent Robert Wood Johnson Foundation survey of physicians indicated that four out of five physicians agreed that unmet social needs are connected to declining health for many Americans. By the same ratio, they also agreed that addressing patients’ social needs are just as important as addressing their medical conditions.  An innovative Boston, Massachusetts organization called Health Leads interviewed local physicians about their needs in providing patient care.  Many expressed frustration that they could not help their poor patients beyond simply providing medical care – with housing, nutrition (food) or other resources that could improve their health.  Not only have these important issues been excluded from the health reform debate, they are largely ignored by policymakers. With a substantial grant from The Physicians Foundation, Health Leads has been able to expand their efforts to train college student volunteers in five cities to “assist” physicians to “prescribe” food, housing and fuel assistance, or other resources for their patients – just as they do medication.  Patients then take those “prescriptions” to the Health Leads Family Help Desks located in clinic waiting rooms, where the volunteers “fill” them by connecting patients with those resources.  Most of the student volunteers (64 percent of who are pre-med students) end up choosing to go into primary care – another plus! Generally exacerbating the overall workforce problem is the plight of medical students now coming into practice.  Graduates, on average, carry a debt of 6,000 and payments of up to ,000 a month!  According to the American Association of Medical Colleges (AAMC), each member of the graduating medical school class of 2033 will face a 0,000 debt! So what can be done to help physicians sustain their practices and have more time with their patients?  An obvious place to start would be to fix the unfair SGR – and promptly!  This Congressional and government inability to solve this problem reminds us of the late economist Milton Friedman’s observation on the inefficacy of government: If you put the government in charge of the Sahara Desert, he said, in five years there will be a shortage of sand.  And so it is with the growing shortage of physicians.  Congress should relieve physicians of onerous and time-consuming regulations and insurance red tape – which do not help patient care and only add to the cost of that care.  It should create more incentives for physicians to go into rural areas and find additional ways for medical students to pay off their medical school loans.  Build more medical schools and increase the number of the 25,000 residents and fellows completing their training every year. Of course, the big question is: Where do you find the money to do all this?  Throughout America’s history, that question has been asked many times.  The obvious answer: If you have the will you can find the wallet.  America always has, if the issue is considered important enough.  It won’t be easy but healthcare delivery and its workforce are being challenged in a major way today, and it will only worsen tomorrow without Congress stepping up and addressing it.  As noted in Shakespeare’s Henry VI: “Delays have dangerous ends.” ### Louis J. Goodman, PhD, is President and Timothy B. Norbeck is CEO of The Physicians Foundation, which is a nonprofit 501(c)(3) organization that seeks to advance the work of practicing physicians and to improve the quality of healthcare for all Americans. It pursues its mission through a variety of activities including grantmaking, research and policy impact studies. Since 2005, The Foundation has awarded numerous multi-year grants totaling more than million.  In addition, The Foundation focuses on the following core areas: health system reform, health information technology, physician leadership, workforce needs and pilot projects.  As the health system in America continues to evolve, The Physicians Foundation is steadfast in its determination to foster the physician / patient relationship and assist physicians in sustaining their medical practices during this evolution. For more information, visit www.physiciansfoundation.org.  ]]> http://www.physiciansnews.com/2012/01/05/a-challenging-road-ahead-for-america%e2%80%99s-physicians/feed/ 6 Physician Mind Shift: The Emergency Department in an ACO World http://www.physiciansnews.com/2012/01/04/physician-mind-shift-the-emergency-department-in-an-aco-world/ http://www.physiciansnews.com/2012/01/04/physician-mind-shift-the-emergency-department-in-an-aco-world/#comments Wed, 04 Jan 2012 20:51:50 +0000 Physicians News http://www.physiciansnews.com/?p=4519 By Mark Crockett, MD In the era of accountable care, you’ll notice that many hospitals and health systems are already driving towards more collaborative workflow. The integrated delivery network (IDN) is changing significantly, and for the better. But in high-acuity care areas, like the emergency department (ED), the challenge of treating patients more holistically in what is already a fast-paced environment is concerning for physicians evaluating the pay-for-performance model. In today’s ED, patients may enter with a chronic condition that could be better managed by a primary care physician (PCP), but because ED physicians are incented to treat sick people in a fee-for-service model, they continue to take these patients on instead of referring them outside the ED walls. If instead both ED and primary care physicians operate as part of a team of care givers that are incented to ensure patients stay healthy and avoid hospital admissions and readmissions, they are headed in the same direction in terms of focusing on better patient outcomes vs. reimbursement dollars. ED physicians used to be among the few physicians employed by the hospital, but that’s changing dramatically as IDNs snap up physician groups. The larger group working together will help make sure the ball isn’t dropped anywhere throughout the spectrum of care. If a patient with a laceration comes into the ED with diabetes, and that ED doc doesn’t think to check blood sugar – because that’s more of a PCP issue – that oversight will be visible in an ACO environment and the physician might be under the microscope in terms of the role played in ensuring quality outcomes. Part of this movement requires implementing integrated technology solutions that provide greater visibility into the types of care needed in your community, allowing the health system to build care facilities that are catered to the population it serves, ultimately enabling the sustainable health community. But the real lynchpin for success is the collaboration between people, not just IT systems. This means choosing metrics to support each constituency that has a stake in the game – providers, payers, physicians and patients – so that they buy into the new strategy and are empowered to make changes that support lower costs, increased efficiencies and higher quality care. It takes strong leadership demanding teamwork across clinical, administrative and even third-party vendors, along with a shared passion for making sure patients are cared for in the best possible way to make this happen. ### Mark Crockett, MD, is chief medical officer for Accountable Care Solutions at OptumInsight. He also practices emergency medicine at Advocate Good Samaritan Hospital in Downer’s Grove, Ill. He maintains a solid understanding of the day-to-day workings of an emergency department and the need for automating the documentation process of this intense environment.]]> http://www.physiciansnews.com/2012/01/04/physician-mind-shift-the-emergency-department-in-an-aco-world/feed/ 0 Attract Patients & Keep Them (Healthy) with Social Media http://www.physiciansnews.com/2011/12/23/attract-patients-keep-them-healthy-with-social-media/ http://www.physiciansnews.com/2011/12/23/attract-patients-keep-them-healthy-with-social-media/#comments Fri, 23 Dec 2011 15:18:46 +0000 Physicians News http://www.physiciansnews.com/?p=4504 By Katie Matlack Over on the Software Advice blog, we discussed ways doctors can use social media for a variety of purposes. A recent study reported over half of all doctors use social media because of the benefit it can add for marketing and business development purposes. Beyond this marketing utility, however, some research has shown that getting information from a doctor after an in-person consultation can make patients more likely to take medicine properly and follow their physician’s instructions.

If you’re ready to get social--social networking, that is--you should prioritize knowing your audience and its habits first, before you ever log in to Facebook or LinkedIn. This involves knowing whether or not they even use social media, first of all. Then, you should figure out what they would like to learn about from you. An easy way to find this out might be to leave a quick paper survey in the waiting room for patients to fill out. Once you know that your patients are on social networks and know what kind of information they’d like, you should identify what kind of content will appeal to them:

Think about your audience. For example, if you’re a pediatrician, preteen patients will probably appreciate links to YouTube videos where Justin Bieber talks on the importance of an active lifestyle. But if you’re a physician serving largely college-aged patients, sharing the Bieber video would paint you as out-of-touch.

The next step is to create a schedule and publish regularly. Start out with a Facebook business page that links to your practice website. Then make the move up to LinkedIn, and create a strong profile that accurately reflects your experience, before you reach out to your current and former colleagues. After you’re publishing one to two times each week and feel comfortable at this rate, you can round out your social media presence with a Twitter account. If you approach social media with the intention of creating a two-sided conversation, and you know what kind of information your patients like to hear, you’ll be in good shape.

To read the rest of the article, you can check out the entire post on the Software Advice Blog.

###

Katie Matlack is the Medical Market Analyst for Software Advice, a company that helps people make choices on electronic medical records software and health information technology.

]]> http://www.physiciansnews.com/2011/12/23/attract-patients-keep-them-healthy-with-social-media/feed/ 0 Year-End 2011 Tax Planning for Physicians http://www.physiciansnews.com/2011/12/13/year-end-2011-tax-planning-for-physicians/ http://www.physiciansnews.com/2011/12/13/year-end-2011-tax-planning-for-physicians/#comments Tue, 13 Dec 2011 15:15:24 +0000 Physicians News http://www.physiciansnews.com/?p=4483 [/caption] By Michael Kline, CPA As the year draws to a close, it is time for medical practices and medical professionals to review the current year’s financial activity and determine if any tax planning opportunities are available to help reduce their overall tax burden. Below are some tax planning tips that can be utilized before year-end that can greatly reduce your tax burden. Depreciation The biggest and easiest 2011 tax-saving opportunity is the accelerated depreciation available until the end of 2011. For many physicians, the purchasing of new equipment can give rise to large deductions in the year the equipment is purchased. Depreciation can be accelerated based on two available tax provisions: bonus depreciation and Section 179 expensing. Bonus depreciation. For qualified assets acquired and placed in service through Dec. 31, 2011, the additional first-year depreciation allowance is 100%. Among the assets that qualify are new tangible medical equipment, computers and off-the-shelf computer software. Additionally, some leased equipment may also qualify, depending on the terms of the lease. With a few exceptions, bonus depreciation is scheduled to drop to 50% in 2012. You may want to purchase and place in service qualifying assets by Dec. 31. Section 179 expensing. This election also allows a 100% deduction for the cost of acquiring qualified assets, but is subject to different rules than bonus depreciation. Unlike the bonus depreciation, used assets can qualify for Section 179 expensing. However, a couple of rules may make Section 179 expensing less beneficial for a medical practice:
  • For 2011, expensing is subject to an annual limit of 0,000, and this limit is phased out dollar for dollar if purchases exceed million for the year. So larger medical practices may not benefit.
  • The election cannot reduce net income below zero. So for businesses that are having a bad year, it can’t be used to create or increase a net operating loss for tax purposes.
The expensing and asset purchase limits are scheduled to drop to 5,000 and 0,000, respectively, in 2012 (though both amounts will be indexed for inflation). Although taking bonus depreciation and/or Section 179 expensing deductions now gives you and your practice immediate deductions for your equipment purchases, it also means you are forgoing deductions that could otherwise be taken later as normal depreciation. In some situations, future deductions could be more valuable. For example, tax rates for individuals are scheduled to go up in 2013, which means flow-through entities, such as partnerships, limited liability companies and S corporations, might save more by deferring the deductions. Retirement plan contributions Many medical practices offer retirement contribution plans, such as 401(K) plans, for their employees. In 2011, the maximum amount that can be contributed by an employee is ,500 and ,000 for participants over 50 years old.  By adding a profit sharing plan in addition to a 401(K) plan, owners of medical practices can increase the amount contributed toward their retirement to ,000.  Although the practice would need to make a contribution for all eligible employees, the plan may be able to be structured to allow most of the contribution by the practice to go the owners. Additionally, the contribution, while deductible on the 2011 tax returns, does not have to be paid until the due date of the practice’s tax return, including extension. Individuals: Income, expenses and AMT Traditional income tax planning calls for deferring income to the next year and accelerating expenses into the current year. This defers taxes to the next year, which generally is beneficial — as long as you’ll be subject to the same (or a lower) marginal rate. Because the 2010 Tax Relief Act extended lower rates through 2012, in 2011 you have the opportunity to take advantage of this traditional strategy (unless you expect to move into a higher tax bracket next year). Potentially controllable income and expense items include:
  • Bonuses or self-employment income
  • State and local income and real estate taxes
  • Mortgage interest
  • Charitable contributions
But this opportunity isn’t without a challenge. Before taking action to time income and expenses, you must consider the alternative minimum tax (AMT). It’s a separate tax system that limits some deductions and doesn’t permit others, such as for state and local income, and real estate taxes and miscellaneous itemized deductions. It also treats certain income items differently. You must calculate your tax liability under both the regular and the AMT systems, and pay the AMT if your AMT liability is higher. So without proper planning, deferring income or accelerating deductions could trigger the AMT or increase AMT liability this year or next. The acceleration of some deductions, such as state and local taxes and some unreimbursed business expenses, could provide you no tax benefit if you are subject to AMT tax. Further complicating matters is the fact that, unlike the regular tax system, the AMT system isn’t regularly adjusted for inflation. Instead, Congress must legislate any adjustments. Typically, it has done so in the form of a “patch.” Such a patch is in effect for 2011 but not for 2012. This makes planning for the AMT — and thus properly timing your income and deductions — especially challenging this year. Gifting and estate planning While estate planning won’t necessarily affect your income tax bill, it’s a good idea to also consider your estate planning goals as year-end approaches. For example, the annual exclusion allows you to gift up to ,000 per year per recipient, gift-tax-free without using up any of your lifetime gift and estate tax exemptions. But unused exclusions don’t carry forward. For example, if you miss the Dec. 31 deadline for making an annual exclusion gift to a particular family member, you cannot make double the gift under the exclusion the next year to make up for it. Also consider the million lifetime gift tax exemption. Although action by Dec. 31, 2011, isn’t required, action by Dec. 31, 2012, may well be. The exemption is scheduled to drop to million on January 1, 2013. The million exemption presents an unprecedented opportunity to transfer substantial wealth to your loved ones tax-free. It may be especially valuable if you are holding assets you expect to increase significantly in value. Making a gift now will remove not only the assets’ current value from your taxable estate, but also all future appreciation on them. Achieve your tax planning goals We’ve discussed only a few of the 2011 tax planning opportunities and challenges. And it’s possible that tax legislation could be signed into law between now and Jan. 1, 2012, that would extend expiring tax breaks or make other changes for 2012 that would affect your 2011 year-end strategies. Further, changes in the economy, the markets or your personal situation could also have an impact. It’s critical to review your tax situation now with your tax advisor and revisit it if anything changes. ### Michael J. Kline is a Certified Public Accountant. A partner in Citrin Cooperman’s Philadelphia office (www.citrincooperman.com), Kline is responsible for client service and quality control, and consults with clients on issues including ownership structure, entity decisions, audits, and multi-state tax and succession planning. Kline can be reached at mkline@citrincooperman.com or 215-545-4800.  ]]> http://www.physiciansnews.com/2011/12/13/year-end-2011-tax-planning-for-physicians/feed/ 0 How to Protect Your Practice From Your Spouse http://www.physiciansnews.com/2011/12/06/how-to-protect-your-practice-from-your-spouse/ http://www.physiciansnews.com/2011/12/06/how-to-protect-your-practice-from-your-spouse/#comments Tue, 06 Dec 2011 15:28:48 +0000 Physicians News http://www.physiciansnews.com/?p=4466 By Deborah B. Miller, Esq.

From a personal perspective, prenuptial agreements are not very appealing, but from a common sense and legal point of view, they can be essential. Getting married is the biggest financial decision in most people’s lives, but many do not consider the financial entanglements that marriage creates.  Just ask anyone who has lost a house or retirement plan in a divorce. Despite reading articles about the importance of using a prenuptial agreement as a tool for planning, plenty of people feel uncomfortable with prenuptial agreements.  Luckily, there are secondary measures, not all as good as a prenuptial agreement, but perhaps more in line with your personal views and the realities of your relationship.  For example, there are ways to structure corporate documents to insulate your medical practice from divorce proceedings, whether your own divorce or that of another physician in your practice.  Buy-sell agreements among shareholders and corporate insurance policies in the event of a forced buyout can be effective tools to protect the practice.  Likewise, postnuptial agreements are an option, even if the prenuptial agreement seemed awkward at the time of marriage.  A postnuptial agreement can be limited to a spouse relinquishing claims on your interest in your medical practice.  This can be a mandatory prerequisite for membership in a practice group, essentially forcing all group members to enter either prenuptial or postnuptial agreements to protect the medical practice from divorce.  This can be effective, as the pressure to enter such an agreement is external, and the blame for needing a postnuptial agreement can be shifted to the attorney for the medical practice.  It’s easy to blame the attorney, just give it a try. Everyone (whether married or not) should make sure their estate plans are up to date and there are a variety of situations in which prenuptial agreements should part of those estate plans.  The most important of these situations are a second marriage, or where at least one spouse has children before the marriage. Let’s start with what happens in a second marriage from a social perspective.  Statistics tell us that 2 out of 3 second marriages fail.  Yet hope springs eternal, as does love, and plenty of divorced folks get remarried.  Those who remarry are more experienced than the first time around, having learned either personally or through a friend the expense and stress associated with a difficult divorce.  Most people have heard about prenuptial agreements, but may not understand how a prenuptial agreement can help them avoid a long and costly divorce, while also protecting their Estate for their children.  Essentially, a prenuptial agreement should streamline a divorce in the event the marriage does not work out, having resolved the marital financial issues before the marriage.  The prenuptial agreement, however, will not address the issues as to any children of the marriage, such as child support and custody.  What it can do for you is to protect your medical practice, your salary, your pension and your retirement account.  It can state how the marital home is to be handled and what property is separate property.  The significance of protecting your medical practice from equitable distribution during a divorce, and your salary from years of alimony cannot be understated. A prenuptial agreement can set forth the financial parameters of the marriage from the day of the wedding up through and including how your Estate is handled after you die.  It can state whether your spouse has a right to an interest in your retirement benefits and your medical practice.  It can state whether or not your spouse waives the right to claim spousal support or alimony.  Some couples do not agree on a straightforward waiver of rights, but instead agree on a sliding scale—the longer the marriage lasts, the greater a dependent spouse’s entitlement to a portion of specified marital property. In addition to setting the financial parameters of your marital relationship, a prenuptial agreement is the best tool to prevent your Estate from ending up in the hands of someone else’s children.  Let’s consider Mom, who at 65 looks great (because she follows her family physician’s advice).  Last year, she married Bob.  Mom has a son and a daughter, but Mom did not get around to having a pre-nuptial agreement...so what happens when Mom dies before Bob and she does not have a will?  If Mom is a resident of Pennsylvania, we need to consider Bob’s statutory right of election.  This law allows, but does not require, Bob to “elect” to take 1/3 of Mom’s Estate.  The right of election exists whether or not Mom has a Will, and regardless of what Mom leaves Bob in her Will.  The only way to cancel this right is by agreement between Mom and Bob. If Bob elects against Mom’s will, he gets 1/3 of Mom’s assets that pass through her Will. Let’s say Mom’s Estate assets are a 0,000 investment account, and her house worth 0,000—a total of 0,000—essentially the money Dad made through hard work and careful saving.  This means that Bob gets 0,000, Mom’s son inherits 0,000, and Mom’s daughter inherits 0,000. Did Mom want Bob to get 0,000 from her Estate? Didn’t Mom always say she would leave everything to her children 50/50? A simple solution would have been a prenuptial agreement stating that Mom and Bob mutually waive their rights to each other’s Estates, including a waiver of their statutory right to claim an Elective Share.  Or, if there was no prenuptial agreement, a post-nuptial agreement is another option.  The agreement to waive the elective share need not occur before the marriage. In the event Mom does not want to leave Bob without anything, Mom and Bob can explore options that express loyalty and respect for her late husband and their children, as well as for Bob’s well-being after she dies.  For example, Mom may wish to grant Bob a life estate in her home, so long as he pays upkeep and taxes or may want to fund a testamentary trust from which Bob can obtain income and support after her death.  Depending on Mom’s wishes and the situation, this can be accomplished in a prenuptial agreement, a Will or by Deed. In second marriages, using Mom above as the ongoing example, there is a particular need to address where Mom will be buried.  If she does not make her intentions as to her remains firmly known, then Pennsylvania law allows Bob as the surviving spouse the unfettered right to decide where she will be buried.  Bob might want her to be buried in Florida near his winter condo.  Mom’s children, however, may want Mom to be buried next to Dad in the established family plot in Pennsylvania.  To resolve this issue, Mom can state her intentions as to her remains in her Will. There are plenty of other marital issues that can be addressed with other proper estate planning tools.  For example, a prenuptial agreement cannot protect Bob’s Estate from bills owed to third parties who provided Mom with “necessaries” such as a hospital care.  Nor can a prenuptial agreement protect Bob’s Estate from the Commonwealth of Pennsylvania seeking dollar-for-dollar reimbursement for all Medicaid benefits provided to Mom.  Depending on which issues are relevant to each couple, there are estate planning tools that can be used to address the various concerns, including placing monies in an irrevocable inter vivos trust. Second marriages involving younger couples are equally fraught with their own types of financial concerns that benefit from a prenuptial agreement.  In the case of younger couples who remarry with children from a prior marriage, the prenuptial agreement should address the thorny issues of how income and assets will be allocated to children and step-children for things ranging from medical expenses, to college tuition, to legal fees for custody and child support proceedings.   ###   Deborah B. Miller, Esquire, is a partner at Strong, Stevens, Miller & Wyant, P.C. (www.strongfirm.com). For follow up, please contact Debbie directly at (610) 239-8600 x 234 or dmiller@strongfirm.com  ]]> http://www.physiciansnews.com/2011/12/06/how-to-protect-your-practice-from-your-spouse/feed/ 0 Uncertainty Doesn’t Have to Mean Loss of Control for Physicians http://www.physiciansnews.com/2012/01/30/practical-implications-of-telemedicine-credentialing/ http://www.physiciansnews.com/2012/01/30/practical-implications-of-telemedicine-credentialing/#comments Mon, 30 Jan 2012 20:03:46 +0000 Physicians News http://www.physiciansnews.com/?p=4569 By Lucia Francesca Bruno, J.D., LL.M., M.B.A. For the past century, information technology has reinvented the familiar and revolutionized the art of medicine.  As health care professionals struggle to keep pace with an ever-changing and consolidating industry, traditional forms of health care have succumbed to modern technology and fiscal constraints.  No longer are patients and providers afforded the luxury of being in the same place at the same time.  Recent developments in patient-service delivery systems have transformed the doctor/patient relationship; paving the way for advances in telemedicine and the credentialing and privileging of telemedicine practitioners.  Inside Look into Telemedicine The Centers for Medicare and Medicaid (“CMS”) defines telemedicine as “the provision of clinical services to patients from a distance via electronic communications.”[1] Although telemedicine is not considered a medical specialty, products and services unique to this practice of medicine often require a costly investment in information technology and the delivery of clinical care by health care providers. Telemedicine seeks to improve a patient’s health by permitting two-way, interactive, communication between the patient and the physician, at a distant-site, for purposes of assessment, diagnosis, and intervention.  Examples of telemedicine include, but are not limited, to the following:  videoconferencing; transmission of still images, and remote monitoring of vital signs. A Past Marred by Obstacles Historically, smaller hospitals and Critical Access Hospitals (“CAHs”) desiring to take advantage of this cost-effective form of clinical care were hampered by duplicative and burdensome Conditions of Participation (“CoPs”) and redundant regulations.   In particular, the credentialing process of obtaining and reviewing practitioner data such as licensure, training, certifications, insurance, and National Practitioner Data Bank queries created a financial burden many hospitals simply could not afford.   Furthermore, many lacked the clinical expertise within their medical staff to evaluate and grant privileges to physicians providing telemedicine services. In a notorious policy brief issued by the National Rural Health Association (“NRHA”) in 2010, providers maintained that “the current telehealth credentialing process was more than an annoyance; it was a deterrent for providers and hospitals, and a barrier to expanding health care access.”[2]  NRHA urged CMS to “adopt a policy that allowed telemedicine providers to receive deemed status (as having met Medicare/Medicaid certification requirements) and permit health care facilities receiving telehealth services to perform credentialing by proxy (delegated credentialing).”[3]  NRHA surmised that “if a provider was already credentialed at a Medicare-participating facility, that credential would be sufficient to provide telemedicine services at another facility; while, the privileging process would remain the responsibility of the originating health care facility.”[4] A Future Swayed by Reason Acknowledging the need for transformational change, on May 5, 2011, CMS introduced the final rule which superseded prior Joint Commission privileging recommendations, and considerably streamlined the credentialing and privileging process for physicians providing telemedicine services. [5] The final rule, effective July 5, 2011, made Federal requirements more flexible and encouraged innovative approaches to the delivery of patient-services; thereby, allowing patients to receive medically necessary interventions in a timelier manner.[6]   In addition to taking a more lenient approach to CoPs, CMS expanded the platform of telemedicine by defining key terms and requiring a written agreement between the "patient-site" and the "distant-site."   The written agreement, subject to disclosure to CMS, must include specific elements and evidence the telemedicine practitioner’s privileges at the “distant-site.” Key Terms Defined by CMS “Telemedicine” is defined as “the provision of clinical services to hospital or CAH patients by practitioners from a distance via electronic communications, either simultaneously or non-simultaneously.”[7] “Simultaneous” telemedicine services are performed in real-time, similar to the actions of an on-site practitioner when called in by an attending physician to see a patient, e.g., teleICU services. [8] “Non-simultaneous” services are clinical services provided to the patient upon a formal request from the patient’s attending physician or practitioner; such services may involve after-the-fact interpretation of diagnostic tests and do not necessarily require the telemedicine practitioner to directly assess the patient in real-time, e.g., teleradiology services.[9] “Distant-site” the location at which the physician or other licensed practitioner delivering the service is located at the time the service is provided via telecommunications.  A “distant-site” is either a Medicare-participating hospital or telemedicine entity (non-Medicare participating hospital) that provides contracted telemedicine services in a manner that enables the hospital or CAH using telemedicine services to meet all applicable CoPs; particularly, those related to the credentialing and privileging of telemedicine practitioners. [10] Written Agreement Required:  Distant-Site Hospital When the distant-site is a Medicare-certified hospital, the final rule requires that the hospital or CAH have a written agreement that expressly states that it is the responsibility of the distant-site hospital to meet the credentialing requirements of 42 C.F.R. 482.12(a)(1)-(a)(7) for hospitals or 42 C.F.R. 485.616(c)(i)-(c)(vii) for CAHs.  In addition, the written agreement must contain the following: (i) the distant-site hospital is a Medicare-participating hospital; (ii) the distant-site practitioner is privileged at the distant-site hospital as evidenced by a current list of the practitioner’s privileges provided by the distant-site hospital; (iii) the practitioner holds a license issued and/or recognized by the state in which the hospital or CAH whose patients receive telemedicine services is located; and (iv) the hospital that credentials and privileges the distant-site practitioner disclose the practitioner’s performance information, e.g., adverse events, complaints, and internal reviews. Written Agreement Required:  Distant-Site Telemedicine Entity To rely on the credentialing and privileging decisions by a distant-site telemedicine entity, the distant-site must affirm, in writing, that the telemedicine entity is a contactor of services to the hospital and furnishes contracted services in a manner that permits the hospital to comply with all applicable CoPs, 42 C.F.R. 482.12(a)(1)-(a)(7) for hospitals or 42 C.F.R. 485.616(c)(i)-(c)(vii) for CAHs.  In addition, the written agreement must contain the following: (i) the distant site’s credentialing and privileging process at least meet the standards in 42 C.F.R. 482.12(a)(1)-(a)(7) and 42 C.F.R. 482.22(a)(1)-(a)(2) when the originating-site is a hospital or 42 C.F.R. 485.616(c)(1)(i)-(c)(1)(vii) when the originating-site is a CAH; (ii) the distant-site practitioner has the experience and expertise as represented by the distant-site telemedicine entity; (iii) the practitioner holds a license issued and/or recognized by the state in which the hospital or CAH is located; and (iv) the hospital or CAH has evidence of an internal review of the distant-site practitioner’s performance of privileges to be exercised at the hospital or CAH; conversely, the hospital or CAH  must send the distant-site entity performance information for use in the entity’s periodic appraisal of the distant-site practitioner. Effect on State Licensure Despite the sweeping reform brought about by the final rule, CMS cautioned that all state-based physician licensure requirements will remain unchanged. Recognizing the fact that “licensure laws and regulations have traditionally been, and continue to be, the provenance of individual States, the final rule does not pre-empt State authority.”[11] Although states remain split on the issue of telemedicine, many states espouse that their existing laws adequately reflect their position on the licensure of telemedicine practitioners.  Other states, however, affirm that a full and unrestricted license is necessary to practice telemedicine, and have reinforced that stance in law or policy.[12] In an effort to address growing concerns amongst medical professionals, the American Medical Association (“AMA”) reaffirmed its policy to support state-based licensure for physicians and oppose national licensure approaches to telemedicine. In its annual assessment of physician licensure, the AMA declared that “telemedicine in particular has crystallized the tension between the states’ role in protecting patients from incompetent physicians and protecting in-state physicians from out-of-state competition, and the desirability of ensuring patients’ access to the highest quality medical advice and treatment possible, wherever located.” [13] Despite tension between the states’ power to regulate health care professionals and the prohibition against restraint on interstate commerce, the practice of telemedicine has yet to be addressed by the courts.  Only time will tell if the final rule is sufficient to spur litigation in this cutting-edge practice of medicine. Informed Consent Considerations Despite comments to CMS encouraging patient informed consent be obtained before the use of telemedicine services by a hospital or CAH, CMS affirmed that under the final rule “there is no difference between distant-site practitioners and in-house or on-site practitioners with respect to informed consent.”[14]  CMS reiterated that “as long as the telemedicine practitioner is performing his or her duties within the privileges granted by the hospital or CAH, in accordance to a policy that requires informed consent, then consent must be obtained regardless of whether treatment is furnished by telemedicine or not.”[15]  For providers, this insightful decision alleviated one more instance of costly red tape.  Medical Staff Bylaws and Standard Operating Procedures In order to ensure full compliance and avoid unnecessary complications, providers are encouraged to amend medical staff bylaws and revise policies and procedures related to credentialing and privileging.  In particular, medical staff bylaws should contain current definitions relevant to telemedicine and an accurate description of the information-sharing process.  Medical staff bylaws should also reflect administrative changes to the provider’s Credentials Committee and Medical Executive Committee, especially as it pertains to clinical services provided by telemedicine. Furthermore, medical staff policies and procedures should be amended to account for changes in clinical protocols, insurance coverage, billing and reimbursement, and HIPAA compliance.   As a precautionary measure, any medical staff policies that require the “physical presence” of a physician should be reevaluated to account for the delivery of patient services by electronic communications. Finally, under the final rule, hospitals and CAHs that take advantage of privileging by proxy must disclose privileged peer review information to the distant-site.  Therefore, it is advisable that hospitals and CAHs carefully assess state-specific peer review guidelines and include language in the written agreement that ensures ongoing protection of peer review information. Conclusion There is no doubt that sweeping changes in the credentialing and privileging process has paved the way for greater advances in telemedicine services.   Dale Alverson, M.D., past president of the American Telemedicine Association surmised that “the final rule will truly help patients receive the care they need, no matter where they live or where their doctor is located.”[16] By eliminating the overly burdensome credentialing and privileging rules in Medicare, Dr. Alverson concluded that “CMS has shown growing support of telemedicine.” [17] Despite the obvious benefits to patients, the long-term ramifications of the final rule on providers are yet, unknown.  Hospitals and CAHs using telemedicine services of distant-site practitioners are, therefore, encouraged to implement adequate policies and procedures to protect their interests and those of their patients. ### Lucia Francesca Bruno, J.D., LL.M., M.B.A., is Principal Shareholder of Physicians’ Legal Group, LLC (www.physicianslegalgroup.com). She can be reached at Lbruno@physicianslegalgroup.com.  

[1] Medicare and Medicaid Programs: Changes Affecting Hospitals and Critical Access Hospital Conditions of Participation: Telemedicine Credentialing and Privileging, 76 Fed. Reg. 25, 551 (May 5, 2011).
[2] Lewis, Pam, Mandy Bell, BA,  Deanna Larson, RN, BSN, and  Jay Weems, MBA:  “Telehealth Provider Credentialing” National Rural Health Association Policy Brief (2010): 1-4.
[3] Lewis, Bell, Larson, Weems, Telehealth Provider Credentialing, 1.
[4] Id. at 1
[5]  Medicare and Medicaid Programs: Changes Affecting Hospitals and Critical Access Hospital Conditions of Participation: Telemedicine   Credentialing and Privileging, 76 Fed. Reg. 25,550, 25,551 (May 5, 2011).
[6] 76 Fed. Reg.  25,551.
[7] Id. at 551.
[8] Id.
[9] Id.
[10] Section 1834(m)(4)(A) of the Social Security Act
[11] 76 Fed. Reg.  25,557.
[12] Office for the Advancement of Telemedicine, “Telemedicine Licensure Report” (2003).
[13] American Medical Association, “Physician Licensure: An Update of Trends” American Medical Association, 2012. Web. 15 January 2012 http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/young-physicians-section/advocacy-resources/physician-licensure-an-update-trends.page.
[14] 76 Fed. Reg.  25,555.
[15] Id. at 255.
[16] http://learntelehealth.org/blog/post/final-ruling-on-credentialing-privileging-of-telehealth-providers/
[17] Id.
]]> http://www.physiciansnews.com/2012/01/30/practical-implications-of-telemedicine-credentialing/feed/ 0 Physicians News » Featured http://www.physiciansnews.com Tue, 07 Feb 2012 16:44:06 +0000 en hourly 1 http://wordpress.org/?v=3.2.1 Help Your Patients Get the Benefits They Deserve http://www.physiciansnews.com/2012/02/01/help-your-patients-get-the-benefits-they-deserve/ http://www.physiciansnews.com/2012/02/01/help-your-patients-get-the-benefits-they-deserve/#comments Wed, 01 Feb 2012 19:07:18 +0000 Physicians News http://www.physiciansnews.com/?p=4583 [/caption] By Eric A. Shore, J.D. and Pia Horton Everyday your patients trust you to care for their health. Many of your patients find themselves unemployed and therefore, uninsured. While some will find work eventually, those with physical and/or mental limitations may not. This is especially true for those approaching retirement age (50-65 years). You can help. Patients who are unable to sustain work due to their health may be eligible for Social Security disability benefits, therefore making them eligible for Medicare or Medicaid. Although treating your patients is obviously your primary concern, taking a few steps to encourage patients to apply and obtain Social Security benefits may be necessary for them to afford the care you provide. Physicians play an instrumental role in helping their patients obtain the Social Security disability benefits they need.  Social Security disability claims are evaluated by determining whether your patient suffers from a severe physical and/or mental impairment that has lasted and/or will last for twelve (12) months, and/or result in your patient's death.  Judges and attorneys review your medical records, looking for your specific documentation of your patient’s physical and mental limitations and how those limitations are caused by your patient's impairments.  To be most helpful, your medical records should also indicate how those limitations prevent or restrict your patient's ability to function on a daily basis. The severity and duration requirements can only be proven by obtaining proper medical evidence, as medical evidence is key to any successful Social Security Disability claim.  Social Security cases are often built and won on the strength of the medical records provided by a client’s treating physician.    Therefore, detailed progress/treatment notes, an accurate accounting of your patient's subjective complaints, referrals to specialists, and referrals for objective testing are necessary to build a winning claim. Your treatment notes are an important part of building the strength of your patient's case.  Consistent treatment should be documented with detailed narratives that include the following: specific dates of treatment, your diagnosis, the nature of your patient’s illness, its etiology, severity, and to what degree the impairment limits your patient’s ability to perform day to day activities, function on a job, and/or maintain full time employment. For example, if your patient has COPD and experiences severe dyspnea, chest pains, wheezing, and fatigue upon minimal exertion, indicate all in your treatment narratives.  Further indicate that medium and heavy exertional level activities are not recommended for your patient, and document specific functional restrictions and/or precautions that your patient should exercise on a daily basis.   Also, note why your patient should not partake in specific exertional activities.  For example, "due to Chronic Obstructive Pulmonary Disease, my patient’s lung volume capacity is severely compromised.  My patient should not lift any weight over ten (10) pounds frequently; never climb ladders; never walk for more than five (5) minutes; avoid vacuuming, dusting, mopping, and standing for more than thirty (30) minutes at a time; avoid all exposure  to dust, chemicals, or other environmental hazards."  Also indicate what adverse effects your patient will experience if he or she partakes in any of the restricted activity Your patient’s subjective complaints are extremely important to record upon every visit to your office.  Often, subjective complaints suggest the true severity of your patient’s impairment and how the impairment limits his or her ability to function.  Subjective complaints of chronic and severe pain should prompt further objective testing, physical therapy, and/or referrals to specialists. The results of objective tests offer concrete evidence that cannot be disputed.  Making timely and accurate referrals for CT scans, MRI’s, and X-rays can strengthen your patient’s case and provide and further confirm your diagnosis.  In addition, timely referrals to specialists and physical therapists document the severity of your patient’s impairment and can significantly increase the chances of winning the claim by indicating your patient’s need for ongoing care and treatment.  With the proper referrals, your patient can build a well documented treatment history, which will in turn bolster your patient’s credibility and increase his or her chances of success.  Moreover, timely objective testing can show permanent impairments, helping to satisfy both the severity requirement and the twelve (12) month duration requirement.  For example, frequently a patient who suffers from severe asthma and/or airway restriction disease is referred for a  Pulmonary Function Testing (PFT).  The results of an initial PFT may only show a mild impairment.  However, over the course of time, your patient's complaints and symptoms may worsen requiring you to refer them for further testing.  Subsequent tests can document how your patient's illness has progressed from tolerable to disabling. Often times, physicians note that their patient is applying for disability benefits, but do not indicate whether they have observed whether their patient is disabled.  Therefore, your observations of how your patient’s impairments affect them should be documented, as well. For example, noting that your patient walks with a limp, experiences frequent falls, has difficulty getting on or off of your examining table, was short of breath walking a short distance, heard voices, could not focus during your exam, could not walk from the waiting room to the treatment room without assistance, winces in pain to your touch, or requires assistive devices to ambulate, can benefit your patient’s claim. When your observations are consistent with your patient's subjective complaints and objective test results, the strength of your patient's claim increases substantially. Moreover, completing simple questionnaires or residual functional capacity (RFC) forms indicating how your patient’s impairments limit their ability to function can be invaluable to your patient’s claim.  Residual Functioning Capacity (RFC) forms and/or Medical Source Statement (MSS) are of great importance to any Social Security disability claim.  The forms help Social Security to evaluate the functional limitations caused by your patient's impairments by giving us insight into how those impairments limit the ability to perform work related activities.  The form consists of a list of physical or mental activities allowing the treating physician to assess their patient's ability to perform work related activities by indicating how the patient’s ability to function is limited by his or her impairment.  More importantly, the form contains sections that allow you to further comment on your patient's limitations in a brief narrative.  In a sense, the form gives you an opportunity to be present at your patients hearing. A supported RFC form completed by you may be the most influential piece of evidence in the case and may actually determine whether your patient will receive the benefits they need.  We know completing forms and copying records for legal matters are not a primary concern. However, because your assistance can be the deciding factor in whether your patient will obtain Medicare/Medicaid and the cash benefits needed to afford transportation to your office, helping patients with their Social Security disability and SSI cases is different. The Social Security Administration must consider all medical evidence of record in your patient's claim including your records and opinions, and give great weight to all evidence submitted by you, the treating physician.  Therefore, your observations, recommendations, referrals, and treatment plans are crucial in assessing your patient’s case and achieving the favorable outcome your patient needs and deserves. ### The Law Offices of Eric A. Shore, P.C. (www.1800cantwork.com) focuses on matters of Social Security Disability and SSI benefits.  They can be reached at 215.627.9999.    ]]> http://www.physiciansnews.com/2012/02/01/help-your-patients-get-the-benefits-they-deserve/feed/ 1 Practical Implications of Telemedicine Credentialing http://www.physiciansnews.com/2012/01/30/practical-implications-of-telemedicine-credentialing/ http://www.physiciansnews.com/2012/01/30/practical-implications-of-telemedicine-credentialing/#comments Mon, 30 Jan 2012 20:03:46 +0000 Physicians News http://www.physiciansnews.com/?p=4569 By Lucia Francesca Bruno, J.D., LL.M., M.B.A. For the past century, information technology has reinvented the familiar and revolutionized the art of medicine.  As health care professionals struggle to keep pace with an ever-changing and consolidating industry, traditional forms of health care have succumbed to modern technology and fiscal constraints.  No longer are patients and providers afforded the luxury of being in the same place at the same time.  Recent developments in patient-service delivery systems have transformed the doctor/patient relationship; paving the way for advances in telemedicine and the credentialing and privileging of telemedicine practitioners.  Inside Look into Telemedicine The Centers for Medicare and Medicaid (“CMS”) defines telemedicine as “the provision of clinical services to patients from a distance via electronic communications.”[1] Although telemedicine is not considered a medical specialty, products and services unique to this practice of medicine often require a costly investment in information technology and the delivery of clinical care by health care providers. Telemedicine seeks to improve a patient’s health by permitting two-way, interactive, communication between the patient and the physician, at a distant-site, for purposes of assessment, diagnosis, and intervention.  Examples of telemedicine include, but are not limited, to the following:  videoconferencing; transmission of still images, and remote monitoring of vital signs. A Past Marred by Obstacles Historically, smaller hospitals and Critical Access Hospitals (“CAHs”) desiring to take advantage of this cost-effective form of clinical care were hampered by duplicative and burdensome Conditions of Participation (“CoPs”) and redundant regulations.   In particular, the credentialing process of obtaining and reviewing practitioner data such as licensure, training, certifications, insurance, and National Practitioner Data Bank queries created a financial burden many hospitals simply could not afford.   Furthermore, many lacked the clinical expertise within their medical staff to evaluate and grant privileges to physicians providing telemedicine services. In a notorious policy brief issued by the National Rural Health Association (“NRHA”) in 2010, providers maintained that “the current telehealth credentialing process was more than an annoyance; it was a deterrent for providers and hospitals, and a barrier to expanding health care access.”[2]  NRHA urged CMS to “adopt a policy that allowed telemedicine providers to receive deemed status (as having met Medicare/Medicaid certification requirements) and permit health care facilities receiving telehealth services to perform credentialing by proxy (delegated credentialing).”[3]  NRHA surmised that “if a provider was already credentialed at a Medicare-participating facility, that credential would be sufficient to provide telemedicine services at another facility; while, the privileging process would remain the responsibility of the originating health care facility.”[4] A Future Swayed by Reason Acknowledging the need for transformational change, on May 5, 2011, CMS introduced the final rule which superseded prior Joint Commission privileging recommendations, and considerably streamlined the credentialing and privileging process for physicians providing telemedicine services. [5] The final rule, effective July 5, 2011, made Federal requirements more flexible and encouraged innovative approaches to the delivery of patient-services; thereby, allowing patients to receive medically necessary interventions in a timelier manner.[6]   In addition to taking a more lenient approach to CoPs, CMS expanded the platform of telemedicine by defining key terms and requiring a written agreement between the "patient-site" and the "distant-site."   The written agreement, subject to disclosure to CMS, must include specific elements and evidence the telemedicine practitioner’s privileges at the “distant-site.” Key Terms Defined by CMS “Telemedicine” is defined as “the provision of clinical services to hospital or CAH patients by practitioners from a distance via electronic communications, either simultaneously or non-simultaneously.”[7] “Simultaneous” telemedicine services are performed in real-time, similar to the actions of an on-site practitioner when called in by an attending physician to see a patient, e.g., teleICU services. [8] “Non-simultaneous” services are clinical services provided to the patient upon a formal request from the patient’s attending physician or practitioner; such services may involve after-the-fact interpretation of diagnostic tests and do not necessarily require the telemedicine practitioner to directly assess the patient in real-time, e.g., teleradiology services.[9] “Distant-site” the location at which the physician or other licensed practitioner delivering the service is located at the time the service is provided via telecommunications.  A “distant-site” is either a Medicare-participating hospital or telemedicine entity (non-Medicare participating hospital) that provides contracted telemedicine services in a manner that enables the hospital or CAH using telemedicine services to meet all applicable CoPs; particularly, those related to the credentialing and privileging of telemedicine practitioners. [10] Written Agreement Required:  Distant-Site Hospital When the distant-site is a Medicare-certified hospital, the final rule requires that the hospital or CAH have a written agreement that expressly states that it is the responsibility of the distant-site hospital to meet the credentialing requirements of 42 C.F.R. 482.12(a)(1)-(a)(7) for hospitals or 42 C.F.R. 485.616(c)(i)-(c)(vii) for CAHs.  In addition, the written agreement must contain the following: (i) the distant-site hospital is a Medicare-participating hospital; (ii) the distant-site practitioner is privileged at the distant-site hospital as evidenced by a current list of the practitioner’s privileges provided by the distant-site hospital; (iii) the practitioner holds a license issued and/or recognized by the state in which the hospital or CAH whose patients receive telemedicine services is located; and (iv) the hospital that credentials and privileges the distant-site practitioner disclose the practitioner’s performance information, e.g., adverse events, complaints, and internal reviews. Written Agreement Required:  Distant-Site Telemedicine Entity To rely on the credentialing and privileging decisions by a distant-site telemedicine entity, the distant-site must affirm, in writing, that the telemedicine entity is a contactor of services to the hospital and furnishes contracted services in a manner that permits the hospital to comply with all applicable CoPs, 42 C.F.R. 482.12(a)(1)-(a)(7) for hospitals or 42 C.F.R. 485.616(c)(i)-(c)(vii) for CAHs.  In addition, the written agreement must contain the following: (i) the distant site’s credentialing and privileging process at least meet the standards in 42 C.F.R. 482.12(a)(1)-(a)(7) and 42 C.F.R. 482.22(a)(1)-(a)(2) when the originating-site is a hospital or 42 C.F.R. 485.616(c)(1)(i)-(c)(1)(vii) when the originating-site is a CAH; (ii) the distant-site practitioner has the experience and expertise as represented by the distant-site telemedicine entity; (iii) the practitioner holds a license issued and/or recognized by the state in which the hospital or CAH is located; and (iv) the hospital or CAH has evidence of an internal review of the distant-site practitioner’s performance of privileges to be exercised at the hospital or CAH; conversely, the hospital or CAH  must send the distant-site entity performance information for use in the entity’s periodic appraisal of the distant-site practitioner. Effect on State Licensure Despite the sweeping reform brought about by the final rule, CMS cautioned that all state-based physician licensure requirements will remain unchanged. Recognizing the fact that “licensure laws and regulations have traditionally been, and continue to be, the provenance of individual States, the final rule does not pre-empt State authority.”[11] Although states remain split on the issue of telemedicine, many states espouse that their existing laws adequately reflect their position on the licensure of telemedicine practitioners.  Other states, however, affirm that a full and unrestricted license is necessary to practice telemedicine, and have reinforced that stance in law or policy.[12] In an effort to address growing concerns amongst medical professionals, the American Medical Association (“AMA”) reaffirmed its policy to support state-based licensure for physicians and oppose national licensure approaches to telemedicine. In its annual assessment of physician licensure, the AMA declared that “telemedicine in particular has crystallized the tension between the states’ role in protecting patients from incompetent physicians and protecting in-state physicians from out-of-state competition, and the desirability of ensuring patients’ access to the highest quality medical advice and treatment possible, wherever located.” [13] Despite tension between the states’ power to regulate health care professionals and the prohibition against restraint on interstate commerce, the practice of telemedicine has yet to be addressed by the courts.  Only time will tell if the final rule is sufficient to spur litigation in this cutting-edge practice of medicine. Informed Consent Considerations Despite comments to CMS encouraging patient informed consent be obtained before the use of telemedicine services by a hospital or CAH, CMS affirmed that under the final rule “there is no difference between distant-site practitioners and in-house or on-site practitioners with respect to informed consent.”[14]  CMS reiterated that “as long as the telemedicine practitioner is performing his or her duties within the privileges granted by the hospital or CAH, in accordance to a policy that requires informed consent, then consent must be obtained regardless of whether treatment is furnished by telemedicine or not.”[15]  For providers, this insightful decision alleviated one more instance of costly red tape.  Medical Staff Bylaws and Standard Operating Procedures In order to ensure full compliance and avoid unnecessary complications, providers are encouraged to amend medical staff bylaws and revise policies and procedures related to credentialing and privileging.  In particular, medical staff bylaws should contain current definitions relevant to telemedicine and an accurate description of the information-sharing process.  Medical staff bylaws should also reflect administrative changes to the provider’s Credentials Committee and Medical Executive Committee, especially as it pertains to clinical services provided by telemedicine. Furthermore, medical staff policies and procedures should be amended to account for changes in clinical protocols, insurance coverage, billing and reimbursement, and HIPAA compliance.   As a precautionary measure, any medical staff policies that require the “physical presence” of a physician should be reevaluated to account for the delivery of patient services by electronic communications. Finally, under the final rule, hospitals and CAHs that take advantage of privileging by proxy must disclose privileged peer review information to the distant-site.  Therefore, it is advisable that hospitals and CAHs carefully assess state-specific peer review guidelines and include language in the written agreement that ensures ongoing protection of peer review information. Conclusion There is no doubt that sweeping changes in the credentialing and privileging process has paved the way for greater advances in telemedicine services.   Dale Alverson, M.D., past president of the American Telemedicine Association surmised that “the final rule will truly help patients receive the care they need, no matter where they live or where their doctor is located.”[16] By eliminating the overly burdensome credentialing and privileging rules in Medicare, Dr. Alverson concluded that “CMS has shown growing support of telemedicine.” [17] Despite the obvious benefits to patients, the long-term ramifications of the final rule on providers are yet, unknown.  Hospitals and CAHs using telemedicine services of distant-site practitioners are, therefore, encouraged to implement adequate policies and procedures to protect their interests and those of their patients. ### Lucia Francesca Bruno, J.D., LL.M., M.B.A., is Principal Shareholder of Physicians’ Legal Group, LLC (www.physicianslegalgroup.com). She can be reached at Lbruno@physicianslegalgroup.com.  

[1] Medicare and Medicaid Programs: Changes Affecting Hospitals and Critical Access Hospital Conditions of Participation: Telemedicine Credentialing and Privileging, 76 Fed. Reg. 25, 551 (May 5, 2011).
[2] Lewis, Pam, Mandy Bell, BA,  Deanna Larson, RN, BSN, and  Jay Weems, MBA:  “Telehealth Provider Credentialing” National Rural Health Association Policy Brief (2010): 1-4.
[3] Lewis, Bell, Larson, Weems, Telehealth Provider Credentialing, 1.
[4] Id. at 1
[5]  Medicare and Medicaid Programs: Changes Affecting Hospitals and Critical Access Hospital Conditions of Participation: Telemedicine   Credentialing and Privileging, 76 Fed. Reg. 25,550, 25,551 (May 5, 2011).
[6] 76 Fed. Reg.  25,551.
[7] Id. at 551.
[8] Id.
[9] Id.
[10] Section 1834(m)(4)(A) of the Social Security Act
[11] 76 Fed. Reg.  25,557.
[12] Office for the Advancement of Telemedicine, “Telemedicine Licensure Report” (2003).
[13] American Medical Association, “Physician Licensure: An Update of Trends” American Medical Association, 2012. Web. 15 January 2012 http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/young-physicians-section/advocacy-resources/physician-licensure-an-update-trends.page.
[14] 76 Fed. Reg.  25,555.
[15] Id. at 255.
[16] http://learntelehealth.org/blog/post/final-ruling-on-credentialing-privileging-of-telehealth-providers/
[17] Id.
]]> http://www.physiciansnews.com/2012/01/30/practical-implications-of-telemedicine-credentialing/feed/ 0 Health Care Reform Debate: More Thought and Less Volume, Please http://www.physiciansnews.com/2012/01/26/health-care-reform-debate-more-thought-and-less-volume-please/ http://www.physiciansnews.com/2012/01/26/health-care-reform-debate-more-thought-and-less-volume-please/#comments Thu, 26 Jan 2012 15:58:22 +0000 Physicians News http://www.physiciansnews.com/?p=4556 By Erika Stewart Health care reform will make huge changes in the way insurance companies do business, but most of that will not go into effect right away. Provisions that will help most Americans in 2012 affect policies that were purchased after March 13, 2010. Under the new laws, health insurance companies cannot:
  • Refuse to cover children under age 19 who have a pre-existing condition
  • Impose a lifetime limit
  • Cancel a policy unless they can prove fraudulent information was given
  • Fail to provide an appeal process for denied claims
New insurance policies must now include reasonable preventive services that carry no copayment or deductible. This includes usual vaccinations, cancer screenings, well-child office visits, blood pressure checks, and tests for such chronic conditions as diabetes and high cholesterol. Children without insurance who have not reached the age of 26 can now be carried on their parents' insurance, even if they are married and no longer live with their parents. Newer health plans must allow the patient to choose a primary care physician and cannot require a referral for an OB/GYN service. The law also prohibits companies from requiring patients to go to a particular emergency room or get prior authorization for emergency care. Effects on Physicians While all this is good news for American families, what about the effect on doctors? Why was the bill endorsed by both the American Medical Association and the American Hospital Association? Primary care physicians will receive more pay from government-sponsored insurance such as Medicare for encouraging patients to take advantage of preventive and outpatient services likely to lower the overall cost of care for individuals. They will also receive incentives for providing coordinated care, and for using electronic health records so that patients are better understood. Hospitals will benefit from reducing the number of charity cases without any payment. By 2014 Americans will receive subsidies to help those with lower income afford medical insurance. Starting in 2014, Medicaid will cover most people who have less than 133 percent of poverty level income. This is projected to bring an additional 16 million people into that system. The impact on states will vary, depending on how generous the Medicaid program is there. The Federal government will cover the cost until 2020 but will then ask states to shoulder more of the burden. With many politicians eyeing cuts to Medicaid in order to bring the budget under control, the poorest of American citizens may be in jeopardy of losing some of their medical care. President Obama has promised to cut 0 billion. House Republicans, led by Paul Ryan, are pushing to change Medicaid to a block grant program and repeal the expansion of coverage. Sustainable Growth Rate (SGR) Another interesting aspect of our health care law is Medicare’s Sustainable Growth Rate (SGR). SGR is defined as the fastest rate at which an organization can grow without collapsing. This figure is used to adjust the Medicare fee schedule so that the fund does not become depleted. If expenditures exceed the SGR, the fee schedule is adjusted downward. However, the formula used does not take into account the increasing volume and complexity of care. A true reflection of program costs must take these factors into consideration. Some critics have complained that the health care reform law does not address this issue. That was not the focus of the bill, which deals mainly with issues of insurance coverage. As the debate about health care reform continues, doctors have weighed in both in favor of the law and concerned about its implications. On her blog “Barking Doc,” Maggie Kozel MD presents her perspective. She says, among other astute comments, that the discussion needs to focus on stewardship. As citizens of this wealthy nation, what is our responsibility? Dr. Kozel is author of “The Color of the Atmosphere: One Doctor’s Journey In and Out of Medicine.” After 10 year’s of practice in Navy medicine, Kozel entered private practice where she was confronted with the inequities of the current system and what that means in terms of patient care. Speaking of the relationship between doctor and patient, she writes, “conversation between doctor and patient is the most undervalued commodity in our health insurance system.” Whether the new law will survive attacks by conservatives, and how well it will address the needed changes in our health care system, remain to be seen. Thoughtful debate on the serious issues involved instead of bickering backed by special interests would help both Congress and the President focus on positive change. As Dr. Kozel writes, what is needed is more thought and less volume.                  ]]> http://www.physiciansnews.com/2012/01/26/health-care-reform-debate-more-thought-and-less-volume-please/feed/ 2 Camden Coalition’s Model for High Needs Patients http://www.physiciansnews.com/2012/01/09/camden-coalition%e2%80%99s-model-for-high-needs-patients/ http://www.physiciansnews.com/2012/01/09/camden-coalition%e2%80%99s-model-for-high-needs-patients/#comments Mon, 09 Jan 2012 15:33:37 +0000 Physicians News http://www.physiciansnews.com/?p=4529 By Jen Abraczinskas and Jeffrey Brenner, MD [caption id="attachment_4531" align="alignleft" width="100" caption="Jen Abraczinskas"][/caption] There is a lot of buzz about reducing hospital readmissions.  But what does a readmission look like?  And what will it take to provide the care needed to avoid readmissions? We arrived at the ICU to find our patient sedated and intubated. Yet only 10 days earlier Mrs. P was strong enough to navigate the halls in her wheel chair, had her diabetes and COPD under control and was taking her medications for bipolar disorder. Mrs. P was discharged with an abundance of home health services – nursing, physical therapy, occupational therapy, home health aid.  How had her condition declined so quickly?  We visited her on day three post-discharge.  Mrs. P was in her living room hospital bed covered in her own body fluids unable to turn herself.  We helped her husband clean her, dress her, and move her into a position where her lungs had a chance to fully expand.  We also checked her blood sugar – slightly over 250.  The rehab center had discharged her with sliding scale insulin and believed that her elderly husband knew how to administer it.  However, when we asked him to try, he only pulled up air into the syringe.  He was not strong enough or organized enough to take care of Mrs. P’s incredibly demanding health needs which required over 10 medications, multiple monthly doctors visits, special transportation, and help with daily living activities.  A 4-day lag in her home health agency opening her case was enough time for Mrs. P’s health status to go from good to seriously troubled. [caption id="attachment_4532" align="alignleft" width="96" caption="Jeffrey Brenner"][/caption] Mrs. P’s experience wasn’t a new one.  The ICU stay was her third admission to the hospital in the last three months.  Initially she had been hospitalized for a COPD exacerbation, sent to rehab, discharged home for several hours before a decline that required another hospital admission and then she repeated this cycle. She was frustrated. Her family was frustrated. And we were frustrated as we watched her careen between the best healthcare Camden has to offer and near neglect of her health needs.  The reasons for the cycle are complex with her greatest complication being our fragmented health system.  During her hospital and rehab stays her health improved because she was receiving daily assistance with her complicated medication regime. Following discharge her inability to use her glucometer, administer insulin, and understand her medications left her vulnerable to rapid health decline.  Since her admissions began, she had been disconnected from primary care and getting her into a new primary care doctor would take weeks.  As her husband battled his own health problems, she needed more assistance at home but did not qualify because her Medicaid application is only just started. Mrs. P’s suffering is also costly. During the last three months, Medicare paid over ,000 for Mrs. P’s 3 admissions, including 2 ICU stays, and 11 weeks of rehab.  Preventing her third readmission alone would have saved Medicare ,482.  Then there is the cost to Mrs. P and her family.  She kept losing the good health she would gain in rehab.  Her husband felt guilty and embarrassed that he could not provide the expert care his wife needed to stop cycling in and out of the hospital.   Sadly, Mrs. P. is not alone in her struggles to stay healthy and out of the hospital.  Everyday in the United States, 10,000 more people turn 65 and many will suffer with multiple chronic illnesses, trouble with transportation, and questions regarding what level of care they truly need.  This population will bill Medicare with its expenses and overburden families with its home health needs. To break the hospitalization cycle and to curb healthcare spending, the Camden Coalition of Healthcare Providers has developed an innovative care management model for high needs / high costs patients in Camden NJ.  The Care Management Team relies on home visits with patients to coordinate doctors’ appointments, transportation, and social services.  The Team provides holistic medical care as well as root cause analysis and solutions to the often intertwined issue of poverty and disease that plague its patients. At any given time the Team sees approximately 35-40 patients. We are often asked why we work so intensely on a hand-full of patients.  From analyzing data gathered from three hospitals in Camden, we found that 1 percent of patients account for 30 percent of costs.  If we focus on the heaviest utilizers of health care, connect them into primary care, and address their needs outside of hospitals, we can begin to bend the cost curve.  The numbers are convincing and inform our overarching mission. But every day we also see the faces of patients needing assistance.  It is our patients’ confrontation with or neglect from our fragmented, difficult to navigate healthcare system that fuels the change we are trying to make. The Care Management Team has seen great success with many patients.  For Mrs. P., we ensured home health arrived soon after her discharge from this ICU stay and continued to communicate with them.  We connected her to a new primary care doctor and arranged transportation to her appointments. We involved her family in a discussion about long term goals and are facilitating her entry into an adult day program.  For other patients, we’ve supported them to achieve permanent housing, affordable medications, and primary and specialty care appointments with doctors who they trust.  Yet, we realize that time-intensive care management often falls into the laps of ill-equipped, overburdened primary care providers, hospital residents or insurance companies.  The Coalition is working to supply providers with tools to reduce the time and cost associated with great care coordination.  The Coalition has developed the Camden Health Information Exchange (HIE) to coordinate the hospital discharge summaries, lab data, and radiology reports for Camden residents.  The Camden HIE allows providers to have up-to-date information on their patients’ conditions and eliminates the need to order repeat tests.  We also are positioning Care Coordination Teams in Camden primary care offices.  The Teams will focus on patients with diabetes or high health care utilization for whom extra care coordination support is needed. As we look to the future, working in a more coordinated fashion is the only way that the needs of our growing, aging population will be met in the United States.  In Camden, we are testing models to improve health care and social services navigation, reduce unnecessary utilization, and equip providers with health information and coordination teams.  If we can support patients in their efforts to attain good health, we will decrease costs and be able to provide more and higher quality services for all. ### The Camden Coalition of Healthcare Providers (www.camdenhealth.org) was created with the overarching mission to improve the health status of all Camden, NJ residents, by increasing the capacity, quality, and access of care in the city.   Jen Abraczinskas is a third year medical student at the University of Pennsylvania and is spending a year with the Coalition as an Americorp volunteer.  Jen is a health coach with the Coalition's high utilizer project. Jeffrey Brenner, MD, is Director, Institute for Urban Health at Cooper University Hospital and Executive Director, Camden Coalition of Healthcare Providers. Naomi Wyatt, the Coalition's Director of Legal and Governmental Affairs, contributed to this article.]]> http://www.physiciansnews.com/2012/01/09/camden-coalition%e2%80%99s-model-for-high-needs-patients/feed/ 1 A Challenging Road Ahead for America’s Physicians http://www.physiciansnews.com/2012/01/05/a-challenging-road-ahead-for-america%e2%80%99s-physicians/ http://www.physiciansnews.com/2012/01/05/a-challenging-road-ahead-for-america%e2%80%99s-physicians/#comments Thu, 05 Jan 2012 15:20:33 +0000 Physicians News http://www.physiciansnews.com/?p=4508 By  Louis J. Goodman and Timothy B. Norbeck  This year promises to be a watershed year for healthcare in general, and for patients and physicians, in particular.  No matter how the U.S. Supreme Court determines the constitutionality of the Patient Protection and Affordable Care Act (PPACA), 2012 will be a crucial turning point in the delivery of healthcare. [caption id="attachment_4511" align="alignleft" width="150" caption="Louis J. Goodman, Ph.D."][/caption] During the Congressional passage of the PPACA, White House advisors acknowledged that the economic forces in the legislation would accelerate physician employment by hospitals and larger physician groups.  As mentioned in the “Roadmap for Physicians to Health Care Reform,” the “private” part of private practice for physicians is disappearing.  Currently, more than 80 percent of visits to physician offices have been to practices with five or fewer physicians.  That will change drastically as more physicians feel pressure to move into larger groups or become employed by hospital systems.  Through October of 2011, there have been 71 hospital mergers. All of this will change the face of the delivery aspect of health care, but a question remains: will it be for the better or worse? Expert opinion is almost universal that there is a present shortage of physicians, especially those in primary care and those practicing in rural areas.  This is a workforce problem that must be addressed now, but it seems to be lost in the debate over the PPACA.  The Physicians Foundation recognizes the shortage problem and recently awarded a large grant to The Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill to develop a dynamic web-based projection model that can be continually updated to track ongoing physician workforce needs across the country.  Information gleaned from the UNC research will further enhance efforts to identify where physicians are most needed to support patients in a growing healthcare system.  Thirty-six percent of practicing physicians are over age 55 and may retire by 2020.  According to Physician Foundation surveys conducted by Merritt Hawkins in 2008 and 2010, fewer physicians are seeing Medicare patients or taking on new Medicare patients.  With 10,000 baby boomers becoming eligible for Medicare every single day, the survey results do not bode well for access to care for Medicare patients. [caption id="attachment_4512" align="alignleft" width="150" caption="Timothy B. Norbeck"][/caption] Why do we have fewer physicians seeing Medicare patients at the very time that we need more of them?  First of all, the Sustainable Growth Rate (SGR) used to pay physicians under Medicare, singles out physicians for financial punishment in the form of payment reductions when volume of service increases.  With an aging population and increasing numbers of chronically ill elderly people, of course the volume of services continues to rise.  However, unless Congress steps in and acts promptly, Medicare physician payments are scheduled for an average reduction of 27.4 percent effective January 1, 2012.  The Physicians Foundation joins all other medical associations and the AARP in warning of the dire consequences on patients’ access to care should this massive and unwarranted reduction go through.  The fatally flawed SGR must be fixed and the aforementioned 27.4 percent scheduled reduction must be stopped. Much has been said about the PPACA, some good and some bad.  We would like to address the legislation from a physician’s point of view.  Physicians are extremely happy to have the American public insured and are delighted to have an end to the discrimination against their patients with pre-existing conditions. They also applaud the new focus on preventive care which should help lead to a healthier public.  As for the downside to the legislation, there was no SGR fix and no tort reform.  The PPACA also assumes a planned 30 percent reduction in physician fees scheduled under the SGR over the next three years.  Furthermore, and this is something that is largely overlooked when discussing the legislation, any physician’s office which mistakenly and by mere accident improperly bills too much for a Medicare visit, is subject to potential liability under federal fraud and abuse statutes. Before the PPACA, intent to commit fraud was necessary for a charge of fraud to be made, but now even an innocent error can result in prosecution.  Finally, and also overlooked by many, is the “translation” fee which must be paid by the treating physician.  If a physician treats a patient who doesn’t speak English and requires a translator, the physician is responsible for the translation fee.  In other words, the translator’s bill would probably exceed the physician’s reimbursement for the office visit! These issues and other pressures on physicians help explain some of the survey results from the 2010 Physicians Foundation Health Reform Research Study, and the numbers only become bleaker when comparing the results from our 2008 survey.  Only one-quarter of physicians surveyed said they plan to continue practicing as they are; while half reported that they would adopt a style of practice different from the traditional full-time independent private practice model.  Hence, the “private” in private practice is going, going, gone! Clearly, increasing administrative burdens attributable to the PPACA requirements plus insurance, red tape and costly regulatory measures are having a likely negative effect on patient care.  Sixty-three percent of physicians surveyed claimed that non-clinical paperwork has caused them to spend less time with their patients and 94 percent said that the time they devote to non-clinical paperwork has increased over the past three years.  Ask any physician what he or she enjoys the most about practicing medicine and the response will be: “seeing, helping and interacting with my patients.” The increasing amount of regulations and paperwork are becoming a more formidable barrier to the joy of practicing medicine.  Add to that the declining reimbursements and difficulty in sustaining one’s practice, the constant threat of liability, decreased time with patients and low or no bargaining power with insurers, it is not surprising to note that general physician morale is low and getting lower. A recent Robert Wood Johnson Foundation survey of physicians indicated that four out of five physicians agreed that unmet social needs are connected to declining health for many Americans. By the same ratio, they also agreed that addressing patients’ social needs are just as important as addressing their medical conditions.  An innovative Boston, Massachusetts organization called Health Leads interviewed local physicians about their needs in providing patient care.  Many expressed frustration that they could not help their poor patients beyond simply providing medical care – with housing, nutrition (food) or other resources that could improve their health.  Not only have these important issues been excluded from the health reform debate, they are largely ignored by policymakers. With a substantial grant from The Physicians Foundation, Health Leads has been able to expand their efforts to train college student volunteers in five cities to “assist” physicians to “prescribe” food, housing and fuel assistance, or other resources for their patients – just as they do medication.  Patients then take those “prescriptions” to the Health Leads Family Help Desks located in clinic waiting rooms, where the volunteers “fill” them by connecting patients with those resources.  Most of the student volunteers (64 percent of who are pre-med students) end up choosing to go into primary care – another plus! Generally exacerbating the overall workforce problem is the plight of medical students now coming into practice.  Graduates, on average, carry a debt of 6,000 and payments of up to ,000 a month!  According to the American Association of Medical Colleges (AAMC), each member of the graduating medical school class of 2033 will face a 0,000 debt! So what can be done to help physicians sustain their practices and have more time with their patients?  An obvious place to start would be to fix the unfair SGR – and promptly!  This Congressional and government inability to solve this problem reminds us of the late economist Milton Friedman’s observation on the inefficacy of government: If you put the government in charge of the Sahara Desert, he said, in five years there will be a shortage of sand.  And so it is with the growing shortage of physicians.  Congress should relieve physicians of onerous and time-consuming regulations and insurance red tape – which do not help patient care and only add to the cost of that care.  It should create more incentives for physicians to go into rural areas and find additional ways for medical students to pay off their medical school loans.  Build more medical schools and increase the number of the 25,000 residents and fellows completing their training every year. Of course, the big question is: Where do you find the money to do all this?  Throughout America’s history, that question has been asked many times.  The obvious answer: If you have the will you can find the wallet.  America always has, if the issue is considered important enough.  It won’t be easy but healthcare delivery and its workforce are being challenged in a major way today, and it will only worsen tomorrow without Congress stepping up and addressing it.  As noted in Shakespeare’s Henry VI: “Delays have dangerous ends.” ### Louis J. Goodman, PhD, is President and Timothy B. Norbeck is CEO of The Physicians Foundation, which is a nonprofit 501(c)(3) organization that seeks to advance the work of practicing physicians and to improve the quality of healthcare for all Americans. It pursues its mission through a variety of activities including grantmaking, research and policy impact studies. Since 2005, The Foundation has awarded numerous multi-year grants totaling more than million.  In addition, The Foundation focuses on the following core areas: health system reform, health information technology, physician leadership, workforce needs and pilot projects.  As the health system in America continues to evolve, The Physicians Foundation is steadfast in its determination to foster the physician / patient relationship and assist physicians in sustaining their medical practices during this evolution. For more information, visit www.physiciansfoundation.org.  ]]> http://www.physiciansnews.com/2012/01/05/a-challenging-road-ahead-for-america%e2%80%99s-physicians/feed/ 6 Physician Mind Shift: The Emergency Department in an ACO World http://www.physiciansnews.com/2012/01/04/physician-mind-shift-the-emergency-department-in-an-aco-world/ http://www.physiciansnews.com/2012/01/04/physician-mind-shift-the-emergency-department-in-an-aco-world/#comments Wed, 04 Jan 2012 20:51:50 +0000 Physicians News http://www.physiciansnews.com/?p=4519 By Mark Crockett, MD In the era of accountable care, you’ll notice that many hospitals and health systems are already driving towards more collaborative workflow. The integrated delivery network (IDN) is changing significantly, and for the better. But in high-acuity care areas, like the emergency department (ED), the challenge of treating patients more holistically in what is already a fast-paced environment is concerning for physicians evaluating the pay-for-performance model. In today’s ED, patients may enter with a chronic condition that could be better managed by a primary care physician (PCP), but because ED physicians are incented to treat sick people in a fee-for-service model, they continue to take these patients on instead of referring them outside the ED walls. If instead both ED and primary care physicians operate as part of a team of care givers that are incented to ensure patients stay healthy and avoid hospital admissions and readmissions, they are headed in the same direction in terms of focusing on better patient outcomes vs. reimbursement dollars. ED physicians used to be among the few physicians employed by the hospital, but that’s changing dramatically as IDNs snap up physician groups. The larger group working together will help make sure the ball isn’t dropped anywhere throughout the spectrum of care. If a patient with a laceration comes into the ED with diabetes, and that ED doc doesn’t think to check blood sugar – because that’s more of a PCP issue – that oversight will be visible in an ACO environment and the physician might be under the microscope in terms of the role played in ensuring quality outcomes. Part of this movement requires implementing integrated technology solutions that provide greater visibility into the types of care needed in your community, allowing the health system to build care facilities that are catered to the population it serves, ultimately enabling the sustainable health community. But the real lynchpin for success is the collaboration between people, not just IT systems. This means choosing metrics to support each constituency that has a stake in the game – providers, payers, physicians and patients – so that they buy into the new strategy and are empowered to make changes that support lower costs, increased efficiencies and higher quality care. It takes strong leadership demanding teamwork across clinical, administrative and even third-party vendors, along with a shared passion for making sure patients are cared for in the best possible way to make this happen. ### Mark Crockett, MD, is chief medical officer for Accountable Care Solutions at OptumInsight. He also practices emergency medicine at Advocate Good Samaritan Hospital in Downer’s Grove, Ill. He maintains a solid understanding of the day-to-day workings of an emergency department and the need for automating the documentation process of this intense environment.]]> http://www.physiciansnews.com/2012/01/04/physician-mind-shift-the-emergency-department-in-an-aco-world/feed/ 0 Attract Patients & Keep Them (Healthy) with Social Media http://www.physiciansnews.com/2011/12/23/attract-patients-keep-them-healthy-with-social-media/ http://www.physiciansnews.com/2011/12/23/attract-patients-keep-them-healthy-with-social-media/#comments Fri, 23 Dec 2011 15:18:46 +0000 Physicians News http://www.physiciansnews.com/?p=4504 By Katie Matlack Over on the Software Advice blog, we discussed ways doctors can use social media for a variety of purposes. A recent study reported over half of all doctors use social media because of the benefit it can add for marketing and business development purposes. Beyond this marketing utility, however, some research has shown that getting information from a doctor after an in-person consultation can make patients more likely to take medicine properly and follow their physician’s instructions.

If you’re ready to get social--social networking, that is--you should prioritize knowing your audience and its habits first, before you ever log in to Facebook or LinkedIn. This involves knowing whether or not they even use social media, first of all. Then, you should figure out what they would like to learn about from you. An easy way to find this out might be to leave a quick paper survey in the waiting room for patients to fill out. Once you know that your patients are on social networks and know what kind of information they’d like, you should identify what kind of content will appeal to them:

Think about your audience. For example, if you’re a pediatrician, preteen patients will probably appreciate links to YouTube videos where Justin Bieber talks on the importance of an active lifestyle. But if you’re a physician serving largely college-aged patients, sharing the Bieber video would paint you as out-of-touch.

The next step is to create a schedule and publish regularly. Start out with a Facebook business page that links to your practice website. Then make the move up to LinkedIn, and create a strong profile that accurately reflects your experience, before you reach out to your current and former colleagues. After you’re publishing one to two times each week and feel comfortable at this rate, you can round out your social media presence with a Twitter account. If you approach social media with the intention of creating a two-sided conversation, and you know what kind of information your patients like to hear, you’ll be in good shape.

To read the rest of the article, you can check out the entire post on the Software Advice Blog.

###

Katie Matlack is the Medical Market Analyst for Software Advice, a company that helps people make choices on electronic medical records software and health information technology.

]]> http://www.physiciansnews.com/2011/12/23/attract-patients-keep-them-healthy-with-social-media/feed/ 0 Year-End 2011 Tax Planning for Physicians http://www.physiciansnews.com/2011/12/13/year-end-2011-tax-planning-for-physicians/ http://www.physiciansnews.com/2011/12/13/year-end-2011-tax-planning-for-physicians/#comments Tue, 13 Dec 2011 15:15:24 +0000 Physicians News http://www.physiciansnews.com/?p=4483 [/caption] By Michael Kline, CPA As the year draws to a close, it is time for medical practices and medical professionals to review the current year’s financial activity and determine if any tax planning opportunities are available to help reduce their overall tax burden. Below are some tax planning tips that can be utilized before year-end that can greatly reduce your tax burden. Depreciation The biggest and easiest 2011 tax-saving opportunity is the accelerated depreciation available until the end of 2011. For many physicians, the purchasing of new equipment can give rise to large deductions in the year the equipment is purchased. Depreciation can be accelerated based on two available tax provisions: bonus depreciation and Section 179 expensing. Bonus depreciation. For qualified assets acquired and placed in service through Dec. 31, 2011, the additional first-year depreciation allowance is 100%. Among the assets that qualify are new tangible medical equipment, computers and off-the-shelf computer software. Additionally, some leased equipment may also qualify, depending on the terms of the lease. With a few exceptions, bonus depreciation is scheduled to drop to 50% in 2012. You may want to purchase and place in service qualifying assets by Dec. 31. Section 179 expensing. This election also allows a 100% deduction for the cost of acquiring qualified assets, but is subject to different rules than bonus depreciation. Unlike the bonus depreciation, used assets can qualify for Section 179 expensing. However, a couple of rules may make Section 179 expensing less beneficial for a medical practice:
  • For 2011, expensing is subject to an annual limit of 0,000, and this limit is phased out dollar for dollar if purchases exceed million for the year. So larger medical practices may not benefit.
  • The election cannot reduce net income below zero. So for businesses that are having a bad year, it can’t be used to create or increase a net operating loss for tax purposes.
The expensing and asset purchase limits are scheduled to drop to 5,000 and 0,000, respectively, in 2012 (though both amounts will be indexed for inflation). Although taking bonus depreciation and/or Section 179 expensing deductions now gives you and your practice immediate deductions for your equipment purchases, it also means you are forgoing deductions that could otherwise be taken later as normal depreciation. In some situations, future deductions could be more valuable. For example, tax rates for individuals are scheduled to go up in 2013, which means flow-through entities, such as partnerships, limited liability companies and S corporations, might save more by deferring the deductions. Retirement plan contributions Many medical practices offer retirement contribution plans, such as 401(K) plans, for their employees. In 2011, the maximum amount that can be contributed by an employee is ,500 and ,000 for participants over 50 years old.  By adding a profit sharing plan in addition to a 401(K) plan, owners of medical practices can increase the amount contributed toward their retirement to ,000.  Although the practice would need to make a contribution for all eligible employees, the plan may be able to be structured to allow most of the contribution by the practice to go the owners. Additionally, the contribution, while deductible on the 2011 tax returns, does not have to be paid until the due date of the practice’s tax return, including extension. Individuals: Income, expenses and AMT Traditional income tax planning calls for deferring income to the next year and accelerating expenses into the current year. This defers taxes to the next year, which generally is beneficial — as long as you’ll be subject to the same (or a lower) marginal rate. Because the 2010 Tax Relief Act extended lower rates through 2012, in 2011 you have the opportunity to take advantage of this traditional strategy (unless you expect to move into a higher tax bracket next year). Potentially controllable income and expense items include:
  • Bonuses or self-employment income
  • State and local income and real estate taxes
  • Mortgage interest
  • Charitable contributions
But this opportunity isn’t without a challenge. Before taking action to time income and expenses, you must consider the alternative minimum tax (AMT). It’s a separate tax system that limits some deductions and doesn’t permit others, such as for state and local income, and real estate taxes and miscellaneous itemized deductions. It also treats certain income items differently. You must calculate your tax liability under both the regular and the AMT systems, and pay the AMT if your AMT liability is higher. So without proper planning, deferring income or accelerating deductions could trigger the AMT or increase AMT liability this year or next. The acceleration of some deductions, such as state and local taxes and some unreimbursed business expenses, could provide you no tax benefit if you are subject to AMT tax. Further complicating matters is the fact that, unlike the regular tax system, the AMT system isn’t regularly adjusted for inflation. Instead, Congress must legislate any adjustments. Typically, it has done so in the form of a “patch.” Such a patch is in effect for 2011 but not for 2012. This makes planning for the AMT — and thus properly timing your income and deductions — especially challenging this year. Gifting and estate planning While estate planning won’t necessarily affect your income tax bill, it’s a good idea to also consider your estate planning goals as year-end approaches. For example, the annual exclusion allows you to gift up to ,000 per year per recipient, gift-tax-free without using up any of your lifetime gift and estate tax exemptions. But unused exclusions don’t carry forward. For example, if you miss the Dec. 31 deadline for making an annual exclusion gift to a particular family member, you cannot make double the gift under the exclusion the next year to make up for it. Also consider the million lifetime gift tax exemption. Although action by Dec. 31, 2011, isn’t required, action by Dec. 31, 2012, may well be. The exemption is scheduled to drop to million on January 1, 2013. The million exemption presents an unprecedented opportunity to transfer substantial wealth to your loved ones tax-free. It may be especially valuable if you are holding assets you expect to increase significantly in value. Making a gift now will remove not only the assets’ current value from your taxable estate, but also all future appreciation on them. Achieve your tax planning goals We’ve discussed only a few of the 2011 tax planning opportunities and challenges. And it’s possible that tax legislation could be signed into law between now and Jan. 1, 2012, that would extend expiring tax breaks or make other changes for 2012 that would affect your 2011 year-end strategies. Further, changes in the economy, the markets or your personal situation could also have an impact. It’s critical to review your tax situation now with your tax advisor and revisit it if anything changes. ### Michael J. Kline is a Certified Public Accountant. A partner in Citrin Cooperman’s Philadelphia office (www.citrincooperman.com), Kline is responsible for client service and quality control, and consults with clients on issues including ownership structure, entity decisions, audits, and multi-state tax and succession planning. Kline can be reached at mkline@citrincooperman.com or 215-545-4800.  ]]> http://www.physiciansnews.com/2011/12/13/year-end-2011-tax-planning-for-physicians/feed/ 0 How to Protect Your Practice From Your Spouse http://www.physiciansnews.com/2011/12/06/how-to-protect-your-practice-from-your-spouse/ http://www.physiciansnews.com/2011/12/06/how-to-protect-your-practice-from-your-spouse/#comments Tue, 06 Dec 2011 15:28:48 +0000 Physicians News http://www.physiciansnews.com/?p=4466 By Deborah B. Miller, Esq.

From a personal perspective, prenuptial agreements are not very appealing, but from a common sense and legal point of view, they can be essential. Getting married is the biggest financial decision in most people’s lives, but many do not consider the financial entanglements that marriage creates.  Just ask anyone who has lost a house or retirement plan in a divorce. Despite reading articles about the importance of using a prenuptial agreement as a tool for planning, plenty of people feel uncomfortable with prenuptial agreements.  Luckily, there are secondary measures, not all as good as a prenuptial agreement, but perhaps more in line with your personal views and the realities of your relationship.  For example, there are ways to structure corporate documents to insulate your medical practice from divorce proceedings, whether your own divorce or that of another physician in your practice.  Buy-sell agreements among shareholders and corporate insurance policies in the event of a forced buyout can be effective tools to protect the practice.  Likewise, postnuptial agreements are an option, even if the prenuptial agreement seemed awkward at the time of marriage.  A postnuptial agreement can be limited to a spouse relinquishing claims on your interest in your medical practice.  This can be a mandatory prerequisite for membership in a practice group, essentially forcing all group members to enter either prenuptial or postnuptial agreements to protect the medical practice from divorce.  This can be effective, as the pressure to enter such an agreement is external, and the blame for needing a postnuptial agreement can be shifted to the attorney for the medical practice.  It’s easy to blame the attorney, just give it a try. Everyone (whether married or not) should make sure their estate plans are up to date and there are a variety of situations in which prenuptial agreements should part of those estate plans.  The most important of these situations are a second marriage, or where at least one spouse has children before the marriage. Let’s start with what happens in a second marriage from a social perspective.  Statistics tell us that 2 out of 3 second marriages fail.  Yet hope springs eternal, as does love, and plenty of divorced folks get remarried.  Those who remarry are more experienced than the first time around, having learned either personally or through a friend the expense and stress associated with a difficult divorce.  Most people have heard about prenuptial agreements, but may not understand how a prenuptial agreement can help them avoid a long and costly divorce, while also protecting their Estate for their children.  Essentially, a prenuptial agreement should streamline a divorce in the event the marriage does not work out, having resolved the marital financial issues before the marriage.  The prenuptial agreement, however, will not address the issues as to any children of the marriage, such as child support and custody.  What it can do for you is to protect your medical practice, your salary, your pension and your retirement account.  It can state how the marital home is to be handled and what property is separate property.  The significance of protecting your medical practice from equitable distribution during a divorce, and your salary from years of alimony cannot be understated. A prenuptial agreement can set forth the financial parameters of the marriage from the day of the wedding up through and including how your Estate is handled after you die.  It can state whether your spouse has a right to an interest in your retirement benefits and your medical practice.  It can state whether or not your spouse waives the right to claim spousal support or alimony.  Some couples do not agree on a straightforward waiver of rights, but instead agree on a sliding scale—the longer the marriage lasts, the greater a dependent spouse’s entitlement to a portion of specified marital property. In addition to setting the financial parameters of your marital relationship, a prenuptial agreement is the best tool to prevent your Estate from ending up in the hands of someone else’s children.  Let’s consider Mom, who at 65 looks great (because she follows her family physician’s advice).  Last year, she married Bob.  Mom has a son and a daughter, but Mom did not get around to having a pre-nuptial agreement...so what happens when Mom dies before Bob and she does not have a will?  If Mom is a resident of Pennsylvania, we need to consider Bob’s statutory right of election.  This law allows, but does not require, Bob to “elect” to take 1/3 of Mom’s Estate.  The right of election exists whether or not Mom has a Will, and regardless of what Mom leaves Bob in her Will.  The only way to cancel this right is by agreement between Mom and Bob. If Bob elects against Mom’s will, he gets 1/3 of Mom’s assets that pass through her Will. Let’s say Mom’s Estate assets are a 0,000 investment account, and her house worth 0,000—a total of 0,000—essentially the money Dad made through hard work and careful saving.  This means that Bob gets 0,000, Mom’s son inherits 0,000, and Mom’s daughter inherits 0,000. Did Mom want Bob to get 0,000 from her Estate? Didn’t Mom always say she would leave everything to her children 50/50? A simple solution would have been a prenuptial agreement stating that Mom and Bob mutually waive their rights to each other’s Estates, including a waiver of their statutory right to claim an Elective Share.  Or, if there was no prenuptial agreement, a post-nuptial agreement is another option.  The agreement to waive the elective share need not occur before the marriage. In the event Mom does not want to leave Bob without anything, Mom and Bob can explore options that express loyalty and respect for her late husband and their children, as well as for Bob’s well-being after she dies.  For example, Mom may wish to grant Bob a life estate in her home, so long as he pays upkeep and taxes or may want to fund a testamentary trust from which Bob can obtain income and support after her death.  Depending on Mom’s wishes and the situation, this can be accomplished in a prenuptial agreement, a Will or by Deed. In second marriages, using Mom above as the ongoing example, there is a particular need to address where Mom will be buried.  If she does not make her intentions as to her remains firmly known, then Pennsylvania law allows Bob as the surviving spouse the unfettered right to decide where she will be buried.  Bob might want her to be buried in Florida near his winter condo.  Mom’s children, however, may want Mom to be buried next to Dad in the established family plot in Pennsylvania.  To resolve this issue, Mom can state her intentions as to her remains in her Will. There are plenty of other marital issues that can be addressed with other proper estate planning tools.  For example, a prenuptial agreement cannot protect Bob’s Estate from bills owed to third parties who provided Mom with “necessaries” such as a hospital care.  Nor can a prenuptial agreement protect Bob’s Estate from the Commonwealth of Pennsylvania seeking dollar-for-dollar reimbursement for all Medicaid benefits provided to Mom.  Depending on which issues are relevant to each couple, there are estate planning tools that can be used to address the various concerns, including placing monies in an irrevocable inter vivos trust. Second marriages involving younger couples are equally fraught with their own types of financial concerns that benefit from a prenuptial agreement.  In the case of younger couples who remarry with children from a prior marriage, the prenuptial agreement should address the thorny issues of how income and assets will be allocated to children and step-children for things ranging from medical expenses, to college tuition, to legal fees for custody and child support proceedings.   ###   Deborah B. Miller, Esquire, is a partner at Strong, Stevens, Miller & Wyant, P.C. (www.strongfirm.com). For follow up, please contact Debbie directly at (610) 239-8600 x 234 or dmiller@strongfirm.com  ]]> http://www.physiciansnews.com/2011/12/06/how-to-protect-your-practice-from-your-spouse/feed/ 0 Uncertainty Doesn’t Have to Mean Loss of Control for Physicians http://www.physiciansnews.com/2012/01/26/health-care-reform-debate-more-thought-and-less-volume-please/ http://www.physiciansnews.com/2012/01/26/health-care-reform-debate-more-thought-and-less-volume-please/#comments Thu, 26 Jan 2012 15:58:22 +0000 Physicians News http://www.physiciansnews.com/?p=4556 By Erika Stewart Health care reform will make huge changes in the way insurance companies do business, but most of that will not go into effect right away. Provisions that will help most Americans in 2012 affect policies that were purchased after March 13, 2010. Under the new laws, health insurance companies cannot:
  • Refuse to cover children under age 19 who have a pre-existing condition
  • Impose a lifetime limit
  • Cancel a policy unless they can prove fraudulent information was given
  • Fail to provide an appeal process for denied claims
New insurance policies must now include reasonable preventive services that carry no copayment or deductible. This includes usual vaccinations, cancer screenings, well-child office visits, blood pressure checks, and tests for such chronic conditions as diabetes and high cholesterol. Children without insurance who have not reached the age of 26 can now be carried on their parents' insurance, even if they are married and no longer live with their parents. Newer health plans must allow the patient to choose a primary care physician and cannot require a referral for an OB/GYN service. The law also prohibits companies from requiring patients to go to a particular emergency room or get prior authorization for emergency care. Effects on Physicians While all this is good news for American families, what about the effect on doctors? Why was the bill endorsed by both the American Medical Association and the American Hospital Association? Primary care physicians will receive more pay from government-sponsored insurance such as Medicare for encouraging patients to take advantage of preventive and outpatient services likely to lower the overall cost of care for individuals. They will also receive incentives for providing coordinated care, and for using electronic health records so that patients are better understood. Hospitals will benefit from reducing the number of charity cases without any payment. By 2014 Americans will receive subsidies to help those with lower income afford medical insurance. Starting in 2014, Medicaid will cover most people who have less than 133 percent of poverty level income. This is projected to bring an additional 16 million people into that system. The impact on states will vary, depending on how generous the Medicaid program is there. The Federal government will cover the cost until 2020 but will then ask states to shoulder more of the burden. With many politicians eyeing cuts to Medicaid in order to bring the budget under control, the poorest of American citizens may be in jeopardy of losing some of their medical care. President Obama has promised to cut $100 billion. House Republicans, led by Paul Ryan, are pushing to change Medicaid to a block grant program and repeal the expansion of coverage. Sustainable Growth Rate (SGR) Another interesting aspect of our health care law is Medicare’s Sustainable Growth Rate (SGR). SGR is defined as the fastest rate at which an organization can grow without collapsing. This figure is used to adjust the Medicare fee schedule so that the fund does not become depleted. If expenditures exceed the SGR, the fee schedule is adjusted downward. However, the formula used does not take into account the increasing volume and complexity of care. A true reflection of program costs must take these factors into consideration. Some critics have complained that the health care reform law does not address this issue. That was not the focus of the bill, which deals mainly with issues of insurance coverage. As the debate about health care reform continues, doctors have weighed in both in favor of the law and concerned about its implications. On her blog “Barking Doc,” Maggie Kozel MD presents her perspective. She says, among other astute comments, that the discussion needs to focus on stewardship. As citizens of this wealthy nation, what is our responsibility? Dr. Kozel is author of “The Color of the Atmosphere: One Doctor’s Journey In and Out of Medicine.” After 10 year’s of practice in Navy medicine, Kozel entered private practice where she was confronted with the inequities of the current system and what that means in terms of patient care. Speaking of the relationship between doctor and patient, she writes, “conversation between doctor and patient is the most undervalued commodity in our health insurance system.” Whether the new law will survive attacks by conservatives, and how well it will address the needed changes in our health care system, remain to be seen. Thoughtful debate on the serious issues involved instead of bickering backed by special interests would help both Congress and the President focus on positive change. As Dr. Kozel writes, what is needed is more thought and less volume.                  ]]> http://www.physiciansnews.com/2012/01/26/health-care-reform-debate-more-thought-and-less-volume-please/feed/ 2 Physicians News » Featured http://www.physiciansnews.com Tue, 07 Feb 2012 16:44:06 +0000 en hourly 1 http://wordpress.org/?v=3.2.1 Help Your Patients Get the Benefits They Deserve http://www.physiciansnews.com/2012/02/01/help-your-patients-get-the-benefits-they-deserve/ http://www.physiciansnews.com/2012/02/01/help-your-patients-get-the-benefits-they-deserve/#comments Wed, 01 Feb 2012 19:07:18 +0000 Physicians News http://www.physiciansnews.com/?p=4583 [/caption] By Eric A. Shore, J.D. and Pia Horton Everyday your patients trust you to care for their health. Many of your patients find themselves unemployed and therefore, uninsured. While some will find work eventually, those with physical and/or mental limitations may not. This is especially true for those approaching retirement age (50-65 years). You can help. Patients who are unable to sustain work due to their health may be eligible for Social Security disability benefits, therefore making them eligible for Medicare or Medicaid. Although treating your patients is obviously your primary concern, taking a few steps to encourage patients to apply and obtain Social Security benefits may be necessary for them to afford the care you provide. Physicians play an instrumental role in helping their patients obtain the Social Security disability benefits they need.  Social Security disability claims are evaluated by determining whether your patient suffers from a severe physical and/or mental impairment that has lasted and/or will last for twelve (12) months, and/or result in your patient's death.  Judges and attorneys review your medical records, looking for your specific documentation of your patient’s physical and mental limitations and how those limitations are caused by your patient's impairments.  To be most helpful, your medical records should also indicate how those limitations prevent or restrict your patient's ability to function on a daily basis. The severity and duration requirements can only be proven by obtaining proper medical evidence, as medical evidence is key to any successful Social Security Disability claim.  Social Security cases are often built and won on the strength of the medical records provided by a client’s treating physician.    Therefore, detailed progress/treatment notes, an accurate accounting of your patient's subjective complaints, referrals to specialists, and referrals for objective testing are necessary to build a winning claim. Your treatment notes are an important part of building the strength of your patient's case.  Consistent treatment should be documented with detailed narratives that include the following: specific dates of treatment, your diagnosis, the nature of your patient’s illness, its etiology, severity, and to what degree the impairment limits your patient’s ability to perform day to day activities, function on a job, and/or maintain full time employment. For example, if your patient has COPD and experiences severe dyspnea, chest pains, wheezing, and fatigue upon minimal exertion, indicate all in your treatment narratives.  Further indicate that medium and heavy exertional level activities are not recommended for your patient, and document specific functional restrictions and/or precautions that your patient should exercise on a daily basis.   Also, note why your patient should not partake in specific exertional activities.  For example, "due to Chronic Obstructive Pulmonary Disease, my patient’s lung volume capacity is severely compromised.  My patient should not lift any weight over ten (10) pounds frequently; never climb ladders; never walk for more than five (5) minutes; avoid vacuuming, dusting, mopping, and standing for more than thirty (30) minutes at a time; avoid all exposure  to dust, chemicals, or other environmental hazards."  Also indicate what adverse effects your patient will experience if he or she partakes in any of the restricted activity Your patient’s subjective complaints are extremely important to record upon every visit to your office.  Often, subjective complaints suggest the true severity of your patient’s impairment and how the impairment limits his or her ability to function.  Subjective complaints of chronic and severe pain should prompt further objective testing, physical therapy, and/or referrals to specialists. The results of objective tests offer concrete evidence that cannot be disputed.  Making timely and accurate referrals for CT scans, MRI’s, and X-rays can strengthen your patient’s case and provide and further confirm your diagnosis.  In addition, timely referrals to specialists and physical therapists document the severity of your patient’s impairment and can significantly increase the chances of winning the claim by indicating your patient’s need for ongoing care and treatment.  With the proper referrals, your patient can build a well documented treatment history, which will in turn bolster your patient’s credibility and increase his or her chances of success.  Moreover, timely objective testing can show permanent impairments, helping to satisfy both the severity requirement and the twelve (12) month duration requirement.  For example, frequently a patient who suffers from severe asthma and/or airway restriction disease is referred for a  Pulmonary Function Testing (PFT).  The results of an initial PFT may only show a mild impairment.  However, over the course of time, your patient's complaints and symptoms may worsen requiring you to refer them for further testing.  Subsequent tests can document how your patient's illness has progressed from tolerable to disabling. Often times, physicians note that their patient is applying for disability benefits, but do not indicate whether they have observed whether their patient is disabled.  Therefore, your observations of how your patient’s impairments affect them should be documented, as well. For example, noting that your patient walks with a limp, experiences frequent falls, has difficulty getting on or off of your examining table, was short of breath walking a short distance, heard voices, could not focus during your exam, could not walk from the waiting room to the treatment room without assistance, winces in pain to your touch, or requires assistive devices to ambulate, can benefit your patient’s claim. When your observations are consistent with your patient's subjective complaints and objective test results, the strength of your patient's claim increases substantially. Moreover, completing simple questionnaires or residual functional capacity (RFC) forms indicating how your patient’s impairments limit their ability to function can be invaluable to your patient’s claim.  Residual Functioning Capacity (RFC) forms and/or Medical Source Statement (MSS) are of great importance to any Social Security disability claim.  The forms help Social Security to evaluate the functional limitations caused by your patient's impairments by giving us insight into how those impairments limit the ability to perform work related activities.  The form consists of a list of physical or mental activities allowing the treating physician to assess their patient's ability to perform work related activities by indicating how the patient’s ability to function is limited by his or her impairment.  More importantly, the form contains sections that allow you to further comment on your patient's limitations in a brief narrative.  In a sense, the form gives you an opportunity to be present at your patients hearing. A supported RFC form completed by you may be the most influential piece of evidence in the case and may actually determine whether your patient will receive the benefits they need.  We know completing forms and copying records for legal matters are not a primary concern. However, because your assistance can be the deciding factor in whether your patient will obtain Medicare/Medicaid and the cash benefits needed to afford transportation to your office, helping patients with their Social Security disability and SSI cases is different. The Social Security Administration must consider all medical evidence of record in your patient's claim including your records and opinions, and give great weight to all evidence submitted by you, the treating physician.  Therefore, your observations, recommendations, referrals, and treatment plans are crucial in assessing your patient’s case and achieving the favorable outcome your patient needs and deserves. ### The Law Offices of Eric A. Shore, P.C. (www.1800cantwork.com) focuses on matters of Social Security Disability and SSI benefits.  They can be reached at 215.627.9999.    ]]> http://www.physiciansnews.com/2012/02/01/help-your-patients-get-the-benefits-they-deserve/feed/ 1 Practical Implications of Telemedicine Credentialing http://www.physiciansnews.com/2012/01/30/practical-implications-of-telemedicine-credentialing/ http://www.physiciansnews.com/2012/01/30/practical-implications-of-telemedicine-credentialing/#comments Mon, 30 Jan 2012 20:03:46 +0000 Physicians News http://www.physiciansnews.com/?p=4569 By Lucia Francesca Bruno, J.D., LL.M., M.B.A. For the past century, information technology has reinvented the familiar and revolutionized the art of medicine.  As health care professionals struggle to keep pace with an ever-changing and consolidating industry, traditional forms of health care have succumbed to modern technology and fiscal constraints.  No longer are patients and providers afforded the luxury of being in the same place at the same time.  Recent developments in patient-service delivery systems have transformed the doctor/patient relationship; paving the way for advances in telemedicine and the credentialing and privileging of telemedicine practitioners.  Inside Look into Telemedicine The Centers for Medicare and Medicaid (“CMS”) defines telemedicine as “the provision of clinical services to patients from a distance via electronic communications.”[1] Although telemedicine is not considered a medical specialty, products and services unique to this practice of medicine often require a costly investment in information technology and the delivery of clinical care by health care providers. Telemedicine seeks to improve a patient’s health by permitting two-way, interactive, communication between the patient and the physician, at a distant-site, for purposes of assessment, diagnosis, and intervention.  Examples of telemedicine include, but are not limited, to the following:  videoconferencing; transmission of still images, and remote monitoring of vital signs. A Past Marred by Obstacles Historically, smaller hospitals and Critical Access Hospitals (“CAHs”) desiring to take advantage of this cost-effective form of clinical care were hampered by duplicative and burdensome Conditions of Participation (“CoPs”) and redundant regulations.   In particular, the credentialing process of obtaining and reviewing practitioner data such as licensure, training, certifications, insurance, and National Practitioner Data Bank queries created a financial burden many hospitals simply could not afford.   Furthermore, many lacked the clinical expertise within their medical staff to evaluate and grant privileges to physicians providing telemedicine services. In a notorious policy brief issued by the National Rural Health Association (“NRHA”) in 2010, providers maintained that “the current telehealth credentialing process was more than an annoyance; it was a deterrent for providers and hospitals, and a barrier to expanding health care access.”[2]  NRHA urged CMS to “adopt a policy that allowed telemedicine providers to receive deemed status (as having met Medicare/Medicaid certification requirements) and permit health care facilities receiving telehealth services to perform credentialing by proxy (delegated credentialing).”[3]  NRHA surmised that “if a provider was already credentialed at a Medicare-participating facility, that credential would be sufficient to provide telemedicine services at another facility; while, the privileging process would remain the responsibility of the originating health care facility.”[4] A Future Swayed by Reason Acknowledging the need for transformational change, on May 5, 2011, CMS introduced the final rule which superseded prior Joint Commission privileging recommendations, and considerably streamlined the credentialing and privileging process for physicians providing telemedicine services. [5] The final rule, effective July 5, 2011, made Federal requirements more flexible and encouraged innovative approaches to the delivery of patient-services; thereby, allowing patients to receive medically necessary interventions in a timelier manner.[6]   In addition to taking a more lenient approach to CoPs, CMS expanded the platform of telemedicine by defining key terms and requiring a written agreement between the "patient-site" and the "distant-site."   The written agreement, subject to disclosure to CMS, must include specific elements and evidence the telemedicine practitioner’s privileges at the “distant-site.” Key Terms Defined by CMS “Telemedicine” is defined as “the provision of clinical services to hospital or CAH patients by practitioners from a distance via electronic communications, either simultaneously or non-simultaneously.”[7] “Simultaneous” telemedicine services are performed in real-time, similar to the actions of an on-site practitioner when called in by an attending physician to see a patient, e.g., teleICU services. [8] “Non-simultaneous” services are clinical services provided to the patient upon a formal request from the patient’s attending physician or practitioner; such services may involve after-the-fact interpretation of diagnostic tests and do not necessarily require the telemedicine practitioner to directly assess the patient in real-time, e.g., teleradiology services.[9] “Distant-site” the location at which the physician or other licensed practitioner delivering the service is located at the time the service is provided via telecommunications.  A “distant-site” is either a Medicare-participating hospital or telemedicine entity (non-Medicare participating hospital) that provides contracted telemedicine services in a manner that enables the hospital or CAH using telemedicine services to meet all applicable CoPs; particularly, those related to the credentialing and privileging of telemedicine practitioners. [10] Written Agreement Required:  Distant-Site Hospital When the distant-site is a Medicare-certified hospital, the final rule requires that the hospital or CAH have a written agreement that expressly states that it is the responsibility of the distant-site hospital to meet the credentialing requirements of 42 C.F.R. 482.12(a)(1)-(a)(7) for hospitals or 42 C.F.R. 485.616(c)(i)-(c)(vii) for CAHs.  In addition, the written agreement must contain the following: (i) the distant-site hospital is a Medicare-participating hospital; (ii) the distant-site practitioner is privileged at the distant-site hospital as evidenced by a current list of the practitioner’s privileges provided by the distant-site hospital; (iii) the practitioner holds a license issued and/or recognized by the state in which the hospital or CAH whose patients receive telemedicine services is located; and (iv) the hospital that credentials and privileges the distant-site practitioner disclose the practitioner’s performance information, e.g., adverse events, complaints, and internal reviews. Written Agreement Required:  Distant-Site Telemedicine Entity To rely on the credentialing and privileging decisions by a distant-site telemedicine entity, the distant-site must affirm, in writing, that the telemedicine entity is a contactor of services to the hospital and furnishes contracted services in a manner that permits the hospital to comply with all applicable CoPs, 42 C.F.R. 482.12(a)(1)-(a)(7) for hospitals or 42 C.F.R. 485.616(c)(i)-(c)(vii) for CAHs.  In addition, the written agreement must contain the following: (i) the distant site’s credentialing and privileging process at least meet the standards in 42 C.F.R. 482.12(a)(1)-(a)(7) and 42 C.F.R. 482.22(a)(1)-(a)(2) when the originating-site is a hospital or 42 C.F.R. 485.616(c)(1)(i)-(c)(1)(vii) when the originating-site is a CAH; (ii) the distant-site practitioner has the experience and expertise as represented by the distant-site telemedicine entity; (iii) the practitioner holds a license issued and/or recognized by the state in which the hospital or CAH is located; and (iv) the hospital or CAH has evidence of an internal review of the distant-site practitioner’s performance of privileges to be exercised at the hospital or CAH; conversely, the hospital or CAH  must send the distant-site entity performance information for use in the entity’s periodic appraisal of the distant-site practitioner. Effect on State Licensure Despite the sweeping reform brought about by the final rule, CMS cautioned that all state-based physician licensure requirements will remain unchanged. Recognizing the fact that “licensure laws and regulations have traditionally been, and continue to be, the provenance of individual States, the final rule does not pre-empt State authority.”[11] Although states remain split on the issue of telemedicine, many states espouse that their existing laws adequately reflect their position on the licensure of telemedicine practitioners.  Other states, however, affirm that a full and unrestricted license is necessary to practice telemedicine, and have reinforced that stance in law or policy.[12] In an effort to address growing concerns amongst medical professionals, the American Medical Association (“AMA”) reaffirmed its policy to support state-based licensure for physicians and oppose national licensure approaches to telemedicine. In its annual assessment of physician licensure, the AMA declared that “telemedicine in particular has crystallized the tension between the states’ role in protecting patients from incompetent physicians and protecting in-state physicians from out-of-state competition, and the desirability of ensuring patients’ access to the highest quality medical advice and treatment possible, wherever located.” [13] Despite tension between the states’ power to regulate health care professionals and the prohibition against restraint on interstate commerce, the practice of telemedicine has yet to be addressed by the courts.  Only time will tell if the final rule is sufficient to spur litigation in this cutting-edge practice of medicine. Informed Consent Considerations Despite comments to CMS encouraging patient informed consent be obtained before the use of telemedicine services by a hospital or CAH, CMS affirmed that under the final rule “there is no difference between distant-site practitioners and in-house or on-site practitioners with respect to informed consent.”[14]  CMS reiterated that “as long as the telemedicine practitioner is performing his or her duties within the privileges granted by the hospital or CAH, in accordance to a policy that requires informed consent, then consent must be obtained regardless of whether treatment is furnished by telemedicine or not.”[15]  For providers, this insightful decision alleviated one more instance of costly red tape.  Medical Staff Bylaws and Standard Operating Procedures In order to ensure full compliance and avoid unnecessary complications, providers are encouraged to amend medical staff bylaws and revise policies and procedures related to credentialing and privileging.  In particular, medical staff bylaws should contain current definitions relevant to telemedicine and an accurate description of the information-sharing process.  Medical staff bylaws should also reflect administrative changes to the provider’s Credentials Committee and Medical Executive Committee, especially as it pertains to clinical services provided by telemedicine. Furthermore, medical staff policies and procedures should be amended to account for changes in clinical protocols, insurance coverage, billing and reimbursement, and HIPAA compliance.   As a precautionary measure, any medical staff policies that require the “physical presence” of a physician should be reevaluated to account for the delivery of patient services by electronic communications. Finally, under the final rule, hospitals and CAHs that take advantage of privileging by proxy must disclose privileged peer review information to the distant-site.  Therefore, it is advisable that hospitals and CAHs carefully assess state-specific peer review guidelines and include language in the written agreement that ensures ongoing protection of peer review information. Conclusion There is no doubt that sweeping changes in the credentialing and privileging process has paved the way for greater advances in telemedicine services.   Dale Alverson, M.D., past president of the American Telemedicine Association surmised that “the final rule will truly help patients receive the care they need, no matter where they live or where their doctor is located.”[16] By eliminating the overly burdensome credentialing and privileging rules in Medicare, Dr. Alverson concluded that “CMS has shown growing support of telemedicine.” [17] Despite the obvious benefits to patients, the long-term ramifications of the final rule on providers are yet, unknown.  Hospitals and CAHs using telemedicine services of distant-site practitioners are, therefore, encouraged to implement adequate policies and procedures to protect their interests and those of their patients. ### Lucia Francesca Bruno, J.D., LL.M., M.B.A., is Principal Shareholder of Physicians’ Legal Group, LLC (www.physicianslegalgroup.com). She can be reached at Lbruno@physicianslegalgroup.com.  

[1] Medicare and Medicaid Programs: Changes Affecting Hospitals and Critical Access Hospital Conditions of Participation: Telemedicine Credentialing and Privileging, 76 Fed. Reg. 25, 551 (May 5, 2011).
[2] Lewis, Pam, Mandy Bell, BA,  Deanna Larson, RN, BSN, and  Jay Weems, MBA:  “Telehealth Provider Credentialing” National Rural Health Association Policy Brief (2010): 1-4.
[3] Lewis, Bell, Larson, Weems, Telehealth Provider Credentialing, 1.
[4] Id. at 1
[5]  Medicare and Medicaid Programs: Changes Affecting Hospitals and Critical Access Hospital Conditions of Participation: Telemedicine   Credentialing and Privileging, 76 Fed. Reg. 25,550, 25,551 (May 5, 2011).
[6] 76 Fed. Reg.  25,551.
[7] Id. at 551.
[8] Id.
[9] Id.
[10] Section 1834(m)(4)(A) of the Social Security Act
[11] 76 Fed. Reg.  25,557.
[12] Office for the Advancement of Telemedicine, “Telemedicine Licensure Report” (2003).
[13] American Medical Association, “Physician Licensure: An Update of Trends” American Medical Association, 2012. Web. 15 January 2012 http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/young-physicians-section/advocacy-resources/physician-licensure-an-update-trends.page.
[14] 76 Fed. Reg.  25,555.
[15] Id. at 255.
[16] http://learntelehealth.org/blog/post/final-ruling-on-credentialing-privileging-of-telehealth-providers/
[17] Id.
]]> http://www.physiciansnews.com/2012/01/30/practical-implications-of-telemedicine-credentialing/feed/ 0 Health Care Reform Debate: More Thought and Less Volume, Please http://www.physiciansnews.com/2012/01/26/health-care-reform-debate-more-thought-and-less-volume-please/ http://www.physiciansnews.com/2012/01/26/health-care-reform-debate-more-thought-and-less-volume-please/#comments Thu, 26 Jan 2012 15:58:22 +0000 Physicians News http://www.physiciansnews.com/?p=4556 By Erika Stewart Health care reform will make huge changes in the way insurance companies do business, but most of that will not go into effect right away. Provisions that will help most Americans in 2012 affect policies that were purchased after March 13, 2010. Under the new laws, health insurance companies cannot:
  • Refuse to cover children under age 19 who have a pre-existing condition
  • Impose a lifetime limit
  • Cancel a policy unless they can prove fraudulent information was given
  • Fail to provide an appeal process for denied claims
New insurance policies must now include reasonable preventive services that carry no copayment or deductible. This includes usual vaccinations, cancer screenings, well-child office visits, blood pressure checks, and tests for such chronic conditions as diabetes and high cholesterol. Children without insurance who have not reached the age of 26 can now be carried on their parents' insurance, even if they are married and no longer live with their parents. Newer health plans must allow the patient to choose a primary care physician and cannot require a referral for an OB/GYN service. The law also prohibits companies from requiring patients to go to a particular emergency room or get prior authorization for emergency care. Effects on Physicians While all this is good news for American families, what about the effect on doctors? Why was the bill endorsed by both the American Medical Association and the American Hospital Association? Primary care physicians will receive more pay from government-sponsored insurance such as Medicare for encouraging patients to take advantage of preventive and outpatient services likely to lower the overall cost of care for individuals. They will also receive incentives for providing coordinated care, and for using electronic health records so that patients are better understood. Hospitals will benefit from reducing the number of charity cases without any payment. By 2014 Americans will receive subsidies to help those with lower income afford medical insurance. Starting in 2014, Medicaid will cover most people who have less than 133 percent of poverty level income. This is projected to bring an additional 16 million people into that system. The impact on states will vary, depending on how generous the Medicaid program is there. The Federal government will cover the cost until 2020 but will then ask states to shoulder more of the burden. With many politicians eyeing cuts to Medicaid in order to bring the budget under control, the poorest of American citizens may be in jeopardy of losing some of their medical care. President Obama has promised to cut 0 billion. House Republicans, led by Paul Ryan, are pushing to change Medicaid to a block grant program and repeal the expansion of coverage. Sustainable Growth Rate (SGR) Another interesting aspect of our health care law is Medicare’s Sustainable Growth Rate (SGR). SGR is defined as the fastest rate at which an organization can grow without collapsing. This figure is used to adjust the Medicare fee schedule so that the fund does not become depleted. If expenditures exceed the SGR, the fee schedule is adjusted downward. However, the formula used does not take into account the increasing volume and complexity of care. A true reflection of program costs must take these factors into consideration. Some critics have complained that the health care reform law does not address this issue. That was not the focus of the bill, which deals mainly with issues of insurance coverage. As the debate about health care reform continues, doctors have weighed in both in favor of the law and concerned about its implications. On her blog “Barking Doc,” Maggie Kozel MD presents her perspective. She says, among other astute comments, that the discussion needs to focus on stewardship. As citizens of this wealthy nation, what is our responsibility? Dr. Kozel is author of “The Color of the Atmosphere: One Doctor’s Journey In and Out of Medicine.” After 10 year’s of practice in Navy medicine, Kozel entered private practice where she was confronted with the inequities of the current system and what that means in terms of patient care. Speaking of the relationship between doctor and patient, she writes, “conversation between doctor and patient is the most undervalued commodity in our health insurance system.” Whether the new law will survive attacks by conservatives, and how well it will address the needed changes in our health care system, remain to be seen. Thoughtful debate on the serious issues involved instead of bickering backed by special interests would help both Congress and the President focus on positive change. As Dr. Kozel writes, what is needed is more thought and less volume.                  ]]> http://www.physiciansnews.com/2012/01/26/health-care-reform-debate-more-thought-and-less-volume-please/feed/ 2 Camden Coalition’s Model for High Needs Patients http://www.physiciansnews.com/2012/01/09/camden-coalition%e2%80%99s-model-for-high-needs-patients/ http://www.physiciansnews.com/2012/01/09/camden-coalition%e2%80%99s-model-for-high-needs-patients/#comments Mon, 09 Jan 2012 15:33:37 +0000 Physicians News http://www.physiciansnews.com/?p=4529 By Jen Abraczinskas and Jeffrey Brenner, MD [caption id="attachment_4531" align="alignleft" width="100" caption="Jen Abraczinskas"][/caption] There is a lot of buzz about reducing hospital readmissions.  But what does a readmission look like?  And what will it take to provide the care needed to avoid readmissions? We arrived at the ICU to find our patient sedated and intubated. Yet only 10 days earlier Mrs. P was strong enough to navigate the halls in her wheel chair, had her diabetes and COPD under control and was taking her medications for bipolar disorder. Mrs. P was discharged with an abundance of home health services – nursing, physical therapy, occupational therapy, home health aid.  How had her condition declined so quickly?  We visited her on day three post-discharge.  Mrs. P was in her living room hospital bed covered in her own body fluids unable to turn herself.  We helped her husband clean her, dress her, and move her into a position where her lungs had a chance to fully expand.  We also checked her blood sugar – slightly over 250.  The rehab center had discharged her with sliding scale insulin and believed that her elderly husband knew how to administer it.  However, when we asked him to try, he only pulled up air into the syringe.  He was not strong enough or organized enough to take care of Mrs. P’s incredibly demanding health needs which required over 10 medications, multiple monthly doctors visits, special transportation, and help with daily living activities.  A 4-day lag in her home health agency opening her case was enough time for Mrs. P’s health status to go from good to seriously troubled. [caption id="attachment_4532" align="alignleft" width="96" caption="Jeffrey Brenner"][/caption] Mrs. P’s experience wasn’t a new one.  The ICU stay was her third admission to the hospital in the last three months.  Initially she had been hospitalized for a COPD exacerbation, sent to rehab, discharged home for several hours before a decline that required another hospital admission and then she repeated this cycle. She was frustrated. Her family was frustrated. And we were frustrated as we watched her careen between the best healthcare Camden has to offer and near neglect of her health needs.  The reasons for the cycle are complex with her greatest complication being our fragmented health system.  During her hospital and rehab stays her health improved because she was receiving daily assistance with her complicated medication regime. Following discharge her inability to use her glucometer, administer insulin, and understand her medications left her vulnerable to rapid health decline.  Since her admissions began, she had been disconnected from primary care and getting her into a new primary care doctor would take weeks.  As her husband battled his own health problems, she needed more assistance at home but did not qualify because her Medicaid application is only just started. Mrs. P’s suffering is also costly. During the last three months, Medicare paid over ,000 for Mrs. P’s 3 admissions, including 2 ICU stays, and 11 weeks of rehab.  Preventing her third readmission alone would have saved Medicare ,482.  Then there is the cost to Mrs. P and her family.  She kept losing the good health she would gain in rehab.  Her husband felt guilty and embarrassed that he could not provide the expert care his wife needed to stop cycling in and out of the hospital.   Sadly, Mrs. P. is not alone in her struggles to stay healthy and out of the hospital.  Everyday in the United States, 10,000 more people turn 65 and many will suffer with multiple chronic illnesses, trouble with transportation, and questions regarding what level of care they truly need.  This population will bill Medicare with its expenses and overburden families with its home health needs. To break the hospitalization cycle and to curb healthcare spending, the Camden Coalition of Healthcare Providers has developed an innovative care management model for high needs / high costs patients in Camden NJ.  The Care Management Team relies on home visits with patients to coordinate doctors’ appointments, transportation, and social services.  The Team provides holistic medical care as well as root cause analysis and solutions to the often intertwined issue of poverty and disease that plague its patients. At any given time the Team sees approximately 35-40 patients. We are often asked why we work so intensely on a hand-full of patients.  From analyzing data gathered from three hospitals in Camden, we found that 1 percent of patients account for 30 percent of costs.  If we focus on the heaviest utilizers of health care, connect them into primary care, and address their needs outside of hospitals, we can begin to bend the cost curve.  The numbers are convincing and inform our overarching mission. But every day we also see the faces of patients needing assistance.  It is our patients’ confrontation with or neglect from our fragmented, difficult to navigate healthcare system that fuels the change we are trying to make. The Care Management Team has seen great success with many patients.  For Mrs. P., we ensured home health arrived soon after her discharge from this ICU stay and continued to communicate with them.  We connected her to a new primary care doctor and arranged transportation to her appointments. We involved her family in a discussion about long term goals and are facilitating her entry into an adult day program.  For other patients, we’ve supported them to achieve permanent housing, affordable medications, and primary and specialty care appointments with doctors who they trust.  Yet, we realize that time-intensive care management often falls into the laps of ill-equipped, overburdened primary care providers, hospital residents or insurance companies.  The Coalition is working to supply providers with tools to reduce the time and cost associated with great care coordination.  The Coalition has developed the Camden Health Information Exchange (HIE) to coordinate the hospital discharge summaries, lab data, and radiology reports for Camden residents.  The Camden HIE allows providers to have up-to-date information on their patients’ conditions and eliminates the need to order repeat tests.  We also are positioning Care Coordination Teams in Camden primary care offices.  The Teams will focus on patients with diabetes or high health care utilization for whom extra care coordination support is needed. As we look to the future, working in a more coordinated fashion is the only way that the needs of our growing, aging population will be met in the United States.  In Camden, we are testing models to improve health care and social services navigation, reduce unnecessary utilization, and equip providers with health information and coordination teams.  If we can support patients in their efforts to attain good health, we will decrease costs and be able to provide more and higher quality services for all. ### The Camden Coalition of Healthcare Providers (www.camdenhealth.org) was created with the overarching mission to improve the health status of all Camden, NJ residents, by increasing the capacity, quality, and access of care in the city.   Jen Abraczinskas is a third year medical student at the University of Pennsylvania and is spending a year with the Coalition as an Americorp volunteer.  Jen is a health coach with the Coalition's high utilizer project. Jeffrey Brenner, MD, is Director, Institute for Urban Health at Cooper University Hospital and Executive Director, Camden Coalition of Healthcare Providers. Naomi Wyatt, the Coalition's Director of Legal and Governmental Affairs, contributed to this article.]]> http://www.physiciansnews.com/2012/01/09/camden-coalition%e2%80%99s-model-for-high-needs-patients/feed/ 1 A Challenging Road Ahead for America’s Physicians http://www.physiciansnews.com/2012/01/05/a-challenging-road-ahead-for-america%e2%80%99s-physicians/ http://www.physiciansnews.com/2012/01/05/a-challenging-road-ahead-for-america%e2%80%99s-physicians/#comments Thu, 05 Jan 2012 15:20:33 +0000 Physicians News http://www.physiciansnews.com/?p=4508 By  Louis J. Goodman and Timothy B. Norbeck  This year promises to be a watershed year for healthcare in general, and for patients and physicians, in particular.  No matter how the U.S. Supreme Court determines the constitutionality of the Patient Protection and Affordable Care Act (PPACA), 2012 will be a crucial turning point in the delivery of healthcare. [caption id="attachment_4511" align="alignleft" width="150" caption="Louis J. Goodman, Ph.D."][/caption] During the Congressional passage of the PPACA, White House advisors acknowledged that the economic forces in the legislation would accelerate physician employment by hospitals and larger physician groups.  As mentioned in the “Roadmap for Physicians to Health Care Reform,” the “private” part of private practice for physicians is disappearing.  Currently, more than 80 percent of visits to physician offices have been to practices with five or fewer physicians.  That will change drastically as more physicians feel pressure to move into larger groups or become employed by hospital systems.  Through October of 2011, there have been 71 hospital mergers. All of this will change the face of the delivery aspect of health care, but a question remains: will it be for the better or worse? Expert opinion is almost universal that there is a present shortage of physicians, especially those in primary care and those practicing in rural areas.  This is a workforce problem that must be addressed now, but it seems to be lost in the debate over the PPACA.  The Physicians Foundation recognizes the shortage problem and recently awarded a large grant to The Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill to develop a dynamic web-based projection model that can be continually updated to track ongoing physician workforce needs across the country.  Information gleaned from the UNC research will further enhance efforts to identify where physicians are most needed to support patients in a growing healthcare system.  Thirty-six percent of practicing physicians are over age 55 and may retire by 2020.  According to Physician Foundation surveys conducted by Merritt Hawkins in 2008 and 2010, fewer physicians are seeing Medicare patients or taking on new Medicare patients.  With 10,000 baby boomers becoming eligible for Medicare every single day, the survey results do not bode well for access to care for Medicare patients. [caption id="attachment_4512" align="alignleft" width="150" caption="Timothy B. Norbeck"][/caption] Why do we have fewer physicians seeing Medicare patients at the very time that we need more of them?  First of all, the Sustainable Growth Rate (SGR) used to pay physicians under Medicare, singles out physicians for financial punishment in the form of payment reductions when volume of service increases.  With an aging population and increasing numbers of chronically ill elderly people, of course the volume of services continues to rise.  However, unless Congress steps in and acts promptly, Medicare physician payments are scheduled for an average reduction of 27.4 percent effective January 1, 2012.  The Physicians Foundation joins all other medical associations and the AARP in warning of the dire consequences on patients’ access to care should this massive and unwarranted reduction go through.  The fatally flawed SGR must be fixed and the aforementioned 27.4 percent scheduled reduction must be stopped. Much has been said about the PPACA, some good and some bad.  We would like to address the legislation from a physician’s point of view.  Physicians are extremely happy to have the American public insured and are delighted to have an end to the discrimination against their patients with pre-existing conditions. They also applaud the new focus on preventive care which should help lead to a healthier public.  As for the downside to the legislation, there was no SGR fix and no tort reform.  The PPACA also assumes a planned 30 percent reduction in physician fees scheduled under the SGR over the next three years.  Furthermore, and this is something that is largely overlooked when discussing the legislation, any physician’s office which mistakenly and by mere accident improperly bills too much for a Medicare visit, is subject to potential liability under federal fraud and abuse statutes. Before the PPACA, intent to commit fraud was necessary for a charge of fraud to be made, but now even an innocent error can result in prosecution.  Finally, and also overlooked by many, is the “translation” fee which must be paid by the treating physician.  If a physician treats a patient who doesn’t speak English and requires a translator, the physician is responsible for the translation fee.  In other words, the translator’s bill would probably exceed the physician’s reimbursement for the office visit! These issues and other pressures on physicians help explain some of the survey results from the 2010 Physicians Foundation Health Reform Research Study, and the numbers only become bleaker when comparing the results from our 2008 survey.  Only one-quarter of physicians surveyed said they plan to continue practicing as they are; while half reported that they would adopt a style of practice different from the traditional full-time independent private practice model.  Hence, the “private” in private practice is going, going, gone! Clearly, increasing administrative burdens attributable to the PPACA requirements plus insurance, red tape and costly regulatory measures are having a likely negative effect on patient care.  Sixty-three percent of physicians surveyed claimed that non-clinical paperwork has caused them to spend less time with their patients and 94 percent said that the time they devote to non-clinical paperwork has increased over the past three years.  Ask any physician what he or she enjoys the most about practicing medicine and the response will be: “seeing, helping and interacting with my patients.” The increasing amount of regulations and paperwork are becoming a more formidable barrier to the joy of practicing medicine.  Add to that the declining reimbursements and difficulty in sustaining one’s practice, the constant threat of liability, decreased time with patients and low or no bargaining power with insurers, it is not surprising to note that general physician morale is low and getting lower. A recent Robert Wood Johnson Foundation survey of physicians indicated that four out of five physicians agreed that unmet social needs are connected to declining health for many Americans. By the same ratio, they also agreed that addressing patients’ social needs are just as important as addressing their medical conditions.  An innovative Boston, Massachusetts organization called Health Leads interviewed local physicians about their needs in providing patient care.  Many expressed frustration that they could not help their poor patients beyond simply providing medical care – with housing, nutrition (food) or other resources that could improve their health.  Not only have these important issues been excluded from the health reform debate, they are largely ignored by policymakers. With a substantial grant from The Physicians Foundation, Health Leads has been able to expand their efforts to train college student volunteers in five cities to “assist” physicians to “prescribe” food, housing and fuel assistance, or other resources for their patients – just as they do medication.  Patients then take those “prescriptions” to the Health Leads Family Help Desks located in clinic waiting rooms, where the volunteers “fill” them by connecting patients with those resources.  Most of the student volunteers (64 percent of who are pre-med students) end up choosing to go into primary care – another plus! Generally exacerbating the overall workforce problem is the plight of medical students now coming into practice.  Graduates, on average, carry a debt of 6,000 and payments of up to ,000 a month!  According to the American Association of Medical Colleges (AAMC), each member of the graduating medical school class of 2033 will face a 0,000 debt! So what can be done to help physicians sustain their practices and have more time with their patients?  An obvious place to start would be to fix the unfair SGR – and promptly!  This Congressional and government inability to solve this problem reminds us of the late economist Milton Friedman’s observation on the inefficacy of government: If you put the government in charge of the Sahara Desert, he said, in five years there will be a shortage of sand.  And so it is with the growing shortage of physicians.  Congress should relieve physicians of onerous and time-consuming regulations and insurance red tape – which do not help patient care and only add to the cost of that care.  It should create more incentives for physicians to go into rural areas and find additional ways for medical students to pay off their medical school loans.  Build more medical schools and increase the number of the 25,000 residents and fellows completing their training every year. Of course, the big question is: Where do you find the money to do all this?  Throughout America’s history, that question has been asked many times.  The obvious answer: If you have the will you can find the wallet.  America always has, if the issue is considered important enough.  It won’t be easy but healthcare delivery and its workforce are being challenged in a major way today, and it will only worsen tomorrow without Congress stepping up and addressing it.  As noted in Shakespeare’s Henry VI: “Delays have dangerous ends.” ### Louis J. Goodman, PhD, is President and Timothy B. Norbeck is CEO of The Physicians Foundation, which is a nonprofit 501(c)(3) organization that seeks to advance the work of practicing physicians and to improve the quality of healthcare for all Americans. It pursues its mission through a variety of activities including grantmaking, research and policy impact studies. Since 2005, The Foundation has awarded numerous multi-year grants totaling more than million.  In addition, The Foundation focuses on the following core areas: health system reform, health information technology, physician leadership, workforce needs and pilot projects.  As the health system in America continues to evolve, The Physicians Foundation is steadfast in its determination to foster the physician / patient relationship and assist physicians in sustaining their medical practices during this evolution. For more information, visit www.physiciansfoundation.org.  ]]> http://www.physiciansnews.com/2012/01/05/a-challenging-road-ahead-for-america%e2%80%99s-physicians/feed/ 6 Physician Mind Shift: The Emergency Department in an ACO World http://www.physiciansnews.com/2012/01/04/physician-mind-shift-the-emergency-department-in-an-aco-world/ http://www.physiciansnews.com/2012/01/04/physician-mind-shift-the-emergency-department-in-an-aco-world/#comments Wed, 04 Jan 2012 20:51:50 +0000 Physicians News http://www.physiciansnews.com/?p=4519 By Mark Crockett, MD In the era of accountable care, you’ll notice that many hospitals and health systems are already driving towards more collaborative workflow. The integrated delivery network (IDN) is changing significantly, and for the better. But in high-acuity care areas, like the emergency department (ED), the challenge of treating patients more holistically in what is already a fast-paced environment is concerning for physicians evaluating the pay-for-performance model. In today’s ED, patients may enter with a chronic condition that could be better managed by a primary care physician (PCP), but because ED physicians are incented to treat sick people in a fee-for-service model, they continue to take these patients on instead of referring them outside the ED walls. If instead both ED and primary care physicians operate as part of a team of care givers that are incented to ensure patients stay healthy and avoid hospital admissions and readmissions, they are headed in the same direction in terms of focusing on better patient outcomes vs. reimbursement dollars. ED physicians used to be among the few physicians employed by the hospital, but that’s changing dramatically as IDNs snap up physician groups. The larger group working together will help make sure the ball isn’t dropped anywhere throughout the spectrum of care. If a patient with a laceration comes into the ED with diabetes, and that ED doc doesn’t think to check blood sugar – because that’s more of a PCP issue – that oversight will be visible in an ACO environment and the physician might be under the microscope in terms of the role played in ensuring quality outcomes. Part of this movement requires implementing integrated technology solutions that provide greater visibility into the types of care needed in your community, allowing the health system to build care facilities that are catered to the population it serves, ultimately enabling the sustainable health community. But the real lynchpin for success is the collaboration between people, not just IT systems. This means choosing metrics to support each constituency that has a stake in the game – providers, payers, physicians and patients – so that they buy into the new strategy and are empowered to make changes that support lower costs, increased efficiencies and higher quality care. It takes strong leadership demanding teamwork across clinical, administrative and even third-party vendors, along with a shared passion for making sure patients are cared for in the best possible way to make this happen. ### Mark Crockett, MD, is chief medical officer for Accountable Care Solutions at OptumInsight. He also practices emergency medicine at Advocate Good Samaritan Hospital in Downer’s Grove, Ill. He maintains a solid understanding of the day-to-day workings of an emergency department and the need for automating the documentation process of this intense environment.]]> http://www.physiciansnews.com/2012/01/04/physician-mind-shift-the-emergency-department-in-an-aco-world/feed/ 0 Attract Patients & Keep Them (Healthy) with Social Media http://www.physiciansnews.com/2011/12/23/attract-patients-keep-them-healthy-with-social-media/ http://www.physiciansnews.com/2011/12/23/attract-patients-keep-them-healthy-with-social-media/#comments Fri, 23 Dec 2011 15:18:46 +0000 Physicians News http://www.physiciansnews.com/?p=4504 By Katie Matlack Over on the Software Advice blog, we discussed ways doctors can use social media for a variety of purposes. A recent study reported over half of all doctors use social media because of the benefit it can add for marketing and business development purposes. Beyond this marketing utility, however, some research has shown that getting information from a doctor after an in-person consultation can make patients more likely to take medicine properly and follow their physician’s instructions.

If you’re ready to get social--social networking, that is--you should prioritize knowing your audience and its habits first, before you ever log in to Facebook or LinkedIn. This involves knowing whether or not they even use social media, first of all. Then, you should figure out what they would like to learn about from you. An easy way to find this out might be to leave a quick paper survey in the waiting room for patients to fill out. Once you know that your patients are on social networks and know what kind of information they’d like, you should identify what kind of content will appeal to them:

Think about your audience. For example, if you’re a pediatrician, preteen patients will probably appreciate links to YouTube videos where Justin Bieber talks on the importance of an active lifestyle. But if you’re a physician serving largely college-aged patients, sharing the Bieber video would paint you as out-of-touch.

The next step is to create a schedule and publish regularly. Start out with a Facebook business page that links to your practice website. Then make the move up to LinkedIn, and create a strong profile that accurately reflects your experience, before you reach out to your current and former colleagues. After you’re publishing one to two times each week and feel comfortable at this rate, you can round out your social media presence with a Twitter account. If you approach social media with the intention of creating a two-sided conversation, and you know what kind of information your patients like to hear, you’ll be in good shape.

To read the rest of the article, you can check out the entire post on the Software Advice Blog.

###

Katie Matlack is the Medical Market Analyst for Software Advice, a company that helps people make choices on electronic medical records software and health information technology.

]]> http://www.physiciansnews.com/2011/12/23/attract-patients-keep-them-healthy-with-social-media/feed/ 0 Year-End 2011 Tax Planning for Physicians http://www.physiciansnews.com/2011/12/13/year-end-2011-tax-planning-for-physicians/ http://www.physiciansnews.com/2011/12/13/year-end-2011-tax-planning-for-physicians/#comments Tue, 13 Dec 2011 15:15:24 +0000 Physicians News http://www.physiciansnews.com/?p=4483 [/caption] By Michael Kline, CPA As the year draws to a close, it is time for medical practices and medical professionals to review the current year’s financial activity and determine if any tax planning opportunities are available to help reduce their overall tax burden. Below are some tax planning tips that can be utilized before year-end that can greatly reduce your tax burden. Depreciation The biggest and easiest 2011 tax-saving opportunity is the accelerated depreciation available until the end of 2011. For many physicians, the purchasing of new equipment can give rise to large deductions in the year the equipment is purchased. Depreciation can be accelerated based on two available tax provisions: bonus depreciation and Section 179 expensing. Bonus depreciation. For qualified assets acquired and placed in service through Dec. 31, 2011, the additional first-year depreciation allowance is 100%. Among the assets that qualify are new tangible medical equipment, computers and off-the-shelf computer software. Additionally, some leased equipment may also qualify, depending on the terms of the lease. With a few exceptions, bonus depreciation is scheduled to drop to 50% in 2012. You may want to purchase and place in service qualifying assets by Dec. 31. Section 179 expensing. This election also allows a 100% deduction for the cost of acquiring qualified assets, but is subject to different rules than bonus depreciation. Unlike the bonus depreciation, used assets can qualify for Section 179 expensing. However, a couple of rules may make Section 179 expensing less beneficial for a medical practice:
  • For 2011, expensing is subject to an annual limit of 0,000, and this limit is phased out dollar for dollar if purchases exceed million for the year. So larger medical practices may not benefit.
  • The election cannot reduce net income below zero. So for businesses that are having a bad year, it can’t be used to create or increase a net operating loss for tax purposes.
The expensing and asset purchase limits are scheduled to drop to 5,000 and 0,000, respectively, in 2012 (though both amounts will be indexed for inflation). Although taking bonus depreciation and/or Section 179 expensing deductions now gives you and your practice immediate deductions for your equipment purchases, it also means you are forgoing deductions that could otherwise be taken later as normal depreciation. In some situations, future deductions could be more valuable. For example, tax rates for individuals are scheduled to go up in 2013, which means flow-through entities, such as partnerships, limited liability companies and S corporations, might save more by deferring the deductions. Retirement plan contributions Many medical practices offer retirement contribution plans, such as 401(K) plans, for their employees. In 2011, the maximum amount that can be contributed by an employee is ,500 and ,000 for participants over 50 years old.  By adding a profit sharing plan in addition to a 401(K) plan, owners of medical practices can increase the amount contributed toward their retirement to ,000.  Although the practice would need to make a contribution for all eligible employees, the plan may be able to be structured to allow most of the contribution by the practice to go the owners. Additionally, the contribution, while deductible on the 2011 tax returns, does not have to be paid until the due date of the practice’s tax return, including extension. Individuals: Income, expenses and AMT Traditional income tax planning calls for deferring income to the next year and accelerating expenses into the current year. This defers taxes to the next year, which generally is beneficial — as long as you’ll be subject to the same (or a lower) marginal rate. Because the 2010 Tax Relief Act extended lower rates through 2012, in 2011 you have the opportunity to take advantage of this traditional strategy (unless you expect to move into a higher tax bracket next year). Potentially controllable income and expense items include:
  • Bonuses or self-employment income
  • State and local income and real estate taxes
  • Mortgage interest
  • Charitable contributions
But this opportunity isn’t without a challenge. Before taking action to time income and expenses, you must consider the alternative minimum tax (AMT). It’s a separate tax system that limits some deductions and doesn’t permit others, such as for state and local income, and real estate taxes and miscellaneous itemized deductions. It also treats certain income items differently. You must calculate your tax liability under both the regular and the AMT systems, and pay the AMT if your AMT liability is higher. So without proper planning, deferring income or accelerating deductions could trigger the AMT or increase AMT liability this year or next. The acceleration of some deductions, such as state and local taxes and some unreimbursed business expenses, could provide you no tax benefit if you are subject to AMT tax. Further complicating matters is the fact that, unlike the regular tax system, the AMT system isn’t regularly adjusted for inflation. Instead, Congress must legislate any adjustments. Typically, it has done so in the form of a “patch.” Such a patch is in effect for 2011 but not for 2012. This makes planning for the AMT — and thus properly timing your income and deductions — especially challenging this year. Gifting and estate planning While estate planning won’t necessarily affect your income tax bill, it’s a good idea to also consider your estate planning goals as year-end approaches. For example, the annual exclusion allows you to gift up to ,000 per year per recipient, gift-tax-free without using up any of your lifetime gift and estate tax exemptions. But unused exclusions don’t carry forward. For example, if you miss the Dec. 31 deadline for making an annual exclusion gift to a particular family member, you cannot make double the gift under the exclusion the next year to make up for it. Also consider the million lifetime gift tax exemption. Although action by Dec. 31, 2011, isn’t required, action by Dec. 31, 2012, may well be. The exemption is scheduled to drop to million on January 1, 2013. The million exemption presents an unprecedented opportunity to transfer substantial wealth to your loved ones tax-free. It may be especially valuable if you are holding assets you expect to increase significantly in value. Making a gift now will remove not only the assets’ current value from your taxable estate, but also all future appreciation on them. Achieve your tax planning goals We’ve discussed only a few of the 2011 tax planning opportunities and challenges. And it’s possible that tax legislation could be signed into law between now and Jan. 1, 2012, that would extend expiring tax breaks or make other changes for 2012 that would affect your 2011 year-end strategies. Further, changes in the economy, the markets or your personal situation could also have an impact. It’s critical to review your tax situation now with your tax advisor and revisit it if anything changes. ### Michael J. Kline is a Certified Public Accountant. A partner in Citrin Cooperman’s Philadelphia office (www.citrincooperman.com), Kline is responsible for client service and quality control, and consults with clients on issues including ownership structure, entity decisions, audits, and multi-state tax and succession planning. Kline can be reached at mkline@citrincooperman.com or 215-545-4800.  ]]> http://www.physiciansnews.com/2011/12/13/year-end-2011-tax-planning-for-physicians/feed/ 0 How to Protect Your Practice From Your Spouse http://www.physiciansnews.com/2011/12/06/how-to-protect-your-practice-from-your-spouse/ http://www.physiciansnews.com/2011/12/06/how-to-protect-your-practice-from-your-spouse/#comments Tue, 06 Dec 2011 15:28:48 +0000 Physicians News http://www.physiciansnews.com/?p=4466 By Deborah B. Miller, Esq.

From a personal perspective, prenuptial agreements are not very appealing, but from a common sense and legal point of view, they can be essential. Getting married is the biggest financial decision in most people’s lives, but many do not consider the financial entanglements that marriage creates.  Just ask anyone who has lost a house or retirement plan in a divorce. Despite reading articles about the importance of using a prenuptial agreement as a tool for planning, plenty of people feel uncomfortable with prenuptial agreements.  Luckily, there are secondary measures, not all as good as a prenuptial agreement, but perhaps more in line with your personal views and the realities of your relationship.  For example, there are ways to structure corporate documents to insulate your medical practice from divorce proceedings, whether your own divorce or that of another physician in your practice.  Buy-sell agreements among shareholders and corporate insurance policies in the event of a forced buyout can be effective tools to protect the practice.  Likewise, postnuptial agreements are an option, even if the prenuptial agreement seemed awkward at the time of marriage.  A postnuptial agreement can be limited to a spouse relinquishing claims on your interest in your medical practice.  This can be a mandatory prerequisite for membership in a practice group, essentially forcing all group members to enter either prenuptial or postnuptial agreements to protect the medical practice from divorce.  This can be effective, as the pressure to enter such an agreement is external, and the blame for needing a postnuptial agreement can be shifted to the attorney for the medical practice.  It’s easy to blame the attorney, just give it a try. Everyone (whether married or not) should make sure their estate plans are up to date and there are a variety of situations in which prenuptial agreements should part of those estate plans.  The most important of these situations are a second marriage, or where at least one spouse has children before the marriage. Let’s start with what happens in a second marriage from a social perspective.  Statistics tell us that 2 out of 3 second marriages fail.  Yet hope springs eternal, as does love, and plenty of divorced folks get remarried.  Those who remarry are more experienced than the first time around, having learned either personally or through a friend the expense and stress associated with a difficult divorce.  Most people have heard about prenuptial agreements, but may not understand how a prenuptial agreement can help them avoid a long and costly divorce, while also protecting their Estate for their children.  Essentially, a prenuptial agreement should streamline a divorce in the event the marriage does not work out, having resolved the marital financial issues before the marriage.  The prenuptial agreement, however, will not address the issues as to any children of the marriage, such as child support and custody.  What it can do for you is to protect your medical practice, your salary, your pension and your retirement account.  It can state how the marital home is to be handled and what property is separate property.  The significance of protecting your medical practice from equitable distribution during a divorce, and your salary from years of alimony cannot be understated. A prenuptial agreement can set forth the financial parameters of the marriage from the day of the wedding up through and including how your Estate is handled after you die.  It can state whether your spouse has a right to an interest in your retirement benefits and your medical practice.  It can state whether or not your spouse waives the right to claim spousal support or alimony.  Some couples do not agree on a straightforward waiver of rights, but instead agree on a sliding scale—the longer the marriage lasts, the greater a dependent spouse’s entitlement to a portion of specified marital property. In addition to setting the financial parameters of your marital relationship, a prenuptial agreement is the best tool to prevent your Estate from ending up in the hands of someone else’s children.  Let’s consider Mom, who at 65 looks great (because she follows her family physician’s advice).  Last year, she married Bob.  Mom has a son and a daughter, but Mom did not get around to having a pre-nuptial agreement...so what happens when Mom dies before Bob and she does not have a will?  If Mom is a resident of Pennsylvania, we need to consider Bob’s statutory right of election.  This law allows, but does not require, Bob to “elect” to take 1/3 of Mom’s Estate.  The right of election exists whether or not Mom has a Will, and regardless of what Mom leaves Bob in her Will.  The only way to cancel this right is by agreement between Mom and Bob. If Bob elects against Mom’s will, he gets 1/3 of Mom’s assets that pass through her Will. Let’s say Mom’s Estate assets are a 0,000 investment account, and her house worth 0,000—a total of 0,000—essentially the money Dad made through hard work and careful saving.  This means that Bob gets 0,000, Mom’s son inherits 0,000, and Mom’s daughter inherits 0,000. Did Mom want Bob to get 0,000 from her Estate? Didn’t Mom always say she would leave everything to her children 50/50? A simple solution would have been a prenuptial agreement stating that Mom and Bob mutually waive their rights to each other’s Estates, including a waiver of their statutory right to claim an Elective Share.  Or, if there was no prenuptial agreement, a post-nuptial agreement is another option.  The agreement to waive the elective share need not occur before the marriage. In the event Mom does not want to leave Bob without anything, Mom and Bob can explore options that express loyalty and respect for her late husband and their children, as well as for Bob’s well-being after she dies.  For example, Mom may wish to grant Bob a life estate in her home, so long as he pays upkeep and taxes or may want to fund a testamentary trust from which Bob can obtain income and support after her death.  Depending on Mom’s wishes and the situation, this can be accomplished in a prenuptial agreement, a Will or by Deed. In second marriages, using Mom above as the ongoing example, there is a particular need to address where Mom will be buried.  If she does not make her intentions as to her remains firmly known, then Pennsylvania law allows Bob as the surviving spouse the unfettered right to decide where she will be buried.  Bob might want her to be buried in Florida near his winter condo.  Mom’s children, however, may want Mom to be buried next to Dad in the established family plot in Pennsylvania.  To resolve this issue, Mom can state her intentions as to her remains in her Will. There are plenty of other marital issues that can be addressed with other proper estate planning tools.  For example, a prenuptial agreement cannot protect Bob’s Estate from bills owed to third parties who provided Mom with “necessaries” such as a hospital care.  Nor can a prenuptial agreement protect Bob’s Estate from the Commonwealth of Pennsylvania seeking dollar-for-dollar reimbursement for all Medicaid benefits provided to Mom.  Depending on which issues are relevant to each couple, there are estate planning tools that can be used to address the various concerns, including placing monies in an irrevocable inter vivos trust. Second marriages involving younger couples are equally fraught with their own types of financial concerns that benefit from a prenuptial agreement.  In the case of younger couples who remarry with children from a prior marriage, the prenuptial agreement should address the thorny issues of how income and assets will be allocated to children and step-children for things ranging from medical expenses, to college tuition, to legal fees for custody and child support proceedings.   ###   Deborah B. Miller, Esquire, is a partner at Strong, Stevens, Miller & Wyant, P.C. (www.strongfirm.com). For follow up, please contact Debbie directly at (610) 239-8600 x 234 or dmiller@strongfirm.com  ]]> http://www.physiciansnews.com/2011/12/06/how-to-protect-your-practice-from-your-spouse/feed/ 0 Uncertainty Doesn’t Have to Mean Loss of Control for Physicians http://www.physiciansnews.com/2012/01/09/camden-coalition%e2%80%99s-model-for-high-needs-patients/ http://www.physiciansnews.com/2012/01/09/camden-coalition%e2%80%99s-model-for-high-needs-patients/#comments Mon, 09 Jan 2012 15:33:37 +0000 Physicians News http://www.physiciansnews.com/?p=4529 By Jen Abraczinskas and Jeffrey Brenner, MD [caption id="attachment_4531" align="alignleft" width="100" caption="Jen Abraczinskas"][/caption] There is a lot of buzz about reducing hospital readmissions.  But what does a readmission look like?  And what will it take to provide the care needed to avoid readmissions? We arrived at the ICU to find our patient sedated and intubated. Yet only 10 days earlier Mrs. P was strong enough to navigate the halls in her wheel chair, had her diabetes and COPD under control and was taking her medications for bipolar disorder. Mrs. P was discharged with an abundance of home health services – nursing, physical therapy, occupational therapy, home health aid.  How had her condition declined so quickly?  We visited her on day three post-discharge.  Mrs. P was in her living room hospital bed covered in her own body fluids unable to turn herself.  We helped her husband clean her, dress her, and move her into a position where her lungs had a chance to fully expand.  We also checked her blood sugar – slightly over 250.  The rehab center had discharged her with sliding scale insulin and believed that her elderly husband knew how to administer it.  However, when we asked him to try, he only pulled up air into the syringe.  He was not strong enough or organized enough to take care of Mrs. P’s incredibly demanding health needs which required over 10 medications, multiple monthly doctors visits, special transportation, and help with daily living activities.  A 4-day lag in her home health agency opening her case was enough time for Mrs. P’s health status to go from good to seriously troubled. [caption id="attachment_4532" align="alignleft" width="96" caption="Jeffrey Brenner"][/caption] Mrs. P’s experience wasn’t a new one.  The ICU stay was her third admission to the hospital in the last three months.  Initially she had been hospitalized for a COPD exacerbation, sent to rehab, discharged home for several hours before a decline that required another hospital admission and then she repeated this cycle. She was frustrated. Her family was frustrated. And we were frustrated as we watched her careen between the best healthcare Camden has to offer and near neglect of her health needs.  The reasons for the cycle are complex with her greatest complication being our fragmented health system.  During her hospital and rehab stays her health improved because she was receiving daily assistance with her complicated medication regime. Following discharge her inability to use her glucometer, administer insulin, and understand her medications left her vulnerable to rapid health decline.  Since her admissions began, she had been disconnected from primary care and getting her into a new primary care doctor would take weeks.  As her husband battled his own health problems, she needed more assistance at home but did not qualify because her Medicaid application is only just started. Mrs. P’s suffering is also costly. During the last three months, Medicare paid over $73,000 for Mrs. P’s 3 admissions, including 2 ICU stays, and 11 weeks of rehab.  Preventing her third readmission alone would have saved Medicare $19,482.  Then there is the cost to Mrs. P and her family.  She kept losing the good health she would gain in rehab.  Her husband felt guilty and embarrassed that he could not provide the expert care his wife needed to stop cycling in and out of the hospital.   Sadly, Mrs. P. is not alone in her struggles to stay healthy and out of the hospital.  Everyday in the United States, 10,000 more people turn 65 and many will suffer with multiple chronic illnesses, trouble with transportation, and questions regarding what level of care they truly need.  This population will bill Medicare with its expenses and overburden families with its home health needs. To break the hospitalization cycle and to curb healthcare spending, the Camden Coalition of Healthcare Providers has developed an innovative care management model for high needs / high costs patients in Camden NJ.  The Care Management Team relies on home visits with patients to coordinate doctors’ appointments, transportation, and social services.  The Team provides holistic medical care as well as root cause analysis and solutions to the often intertwined issue of poverty and disease that plague its patients. At any given time the Team sees approximately 35-40 patients. We are often asked why we work so intensely on a hand-full of patients.  From analyzing data gathered from three hospitals in Camden, we found that 1 percent of patients account for 30 percent of costs.  If we focus on the heaviest utilizers of health care, connect them into primary care, and address their needs outside of hospitals, we can begin to bend the cost curve.  The numbers are convincing and inform our overarching mission. But every day we also see the faces of patients needing assistance.  It is our patients’ confrontation with or neglect from our fragmented, difficult to navigate healthcare system that fuels the change we are trying to make. The Care Management Team has seen great success with many patients.  For Mrs. P., we ensured home health arrived soon after her discharge from this ICU stay and continued to communicate with them.  We connected her to a new primary care doctor and arranged transportation to her appointments. We involved her family in a discussion about long term goals and are facilitating her entry into an adult day program.  For other patients, we’ve supported them to achieve permanent housing, affordable medications, and primary and specialty care appointments with doctors who they trust.  Yet, we realize that time-intensive care management often falls into the laps of ill-equipped, overburdened primary care providers, hospital residents or insurance companies.  The Coalition is working to supply providers with tools to reduce the time and cost associated with great care coordination.  The Coalition has developed the Camden Health Information Exchange (HIE) to coordinate the hospital discharge summaries, lab data, and radiology reports for Camden residents.  The Camden HIE allows providers to have up-to-date information on their patients’ conditions and eliminates the need to order repeat tests.  We also are positioning Care Coordination Teams in Camden primary care offices.  The Teams will focus on patients with diabetes or high health care utilization for whom extra care coordination support is needed. As we look to the future, working in a more coordinated fashion is the only way that the needs of our growing, aging population will be met in the United States.  In Camden, we are testing models to improve health care and social services navigation, reduce unnecessary utilization, and equip providers with health information and coordination teams.  If we can support patients in their efforts to attain good health, we will decrease costs and be able to provide more and higher quality services for all. ### The Camden Coalition of Healthcare Providers (www.camdenhealth.org) was created with the overarching mission to improve the health status of all Camden, NJ residents, by increasing the capacity, quality, and access of care in the city.   Jen Abraczinskas is a third year medical student at the University of Pennsylvania and is spending a year with the Coalition as an Americorp volunteer.  Jen is a health coach with the Coalition's high utilizer project. Jeffrey Brenner, MD, is Director, Institute for Urban Health at Cooper University Hospital and Executive Director, Camden Coalition of Healthcare Providers. Naomi Wyatt, the Coalition's Director of Legal and Governmental Affairs, contributed to this article.]]> http://www.physiciansnews.com/2012/01/09/camden-coalition%e2%80%99s-model-for-high-needs-patients/feed/ 1 Physicians News » Featured http://www.physiciansnews.com Tue, 07 Feb 2012 16:44:06 +0000 en hourly 1 http://wordpress.org/?v=3.2.1 Help Your Patients Get the Benefits They Deserve http://www.physiciansnews.com/2012/02/01/help-your-patients-get-the-benefits-they-deserve/ http://www.physiciansnews.com/2012/02/01/help-your-patients-get-the-benefits-they-deserve/#comments Wed, 01 Feb 2012 19:07:18 +0000 Physicians News http://www.physiciansnews.com/?p=4583 [/caption] By Eric A. Shore, J.D. and Pia Horton Everyday your patients trust you to care for their health. Many of your patients find themselves unemployed and therefore, uninsured. While some will find work eventually, those with physical and/or mental limitations may not. This is especially true for those approaching retirement age (50-65 years). You can help. Patients who are unable to sustain work due to their health may be eligible for Social Security disability benefits, therefore making them eligible for Medicare or Medicaid. Although treating your patients is obviously your primary concern, taking a few steps to encourage patients to apply and obtain Social Security benefits may be necessary for them to afford the care you provide. Physicians play an instrumental role in helping their patients obtain the Social Security disability benefits they need.  Social Security disability claims are evaluated by determining whether your patient suffers from a severe physical and/or mental impairment that has lasted and/or will last for twelve (12) months, and/or result in your patient's death.  Judges and attorneys review your medical records, looking for your specific documentation of your patient’s physical and mental limitations and how those limitations are caused by your patient's impairments.  To be most helpful, your medical records should also indicate how those limitations prevent or restrict your patient's ability to function on a daily basis. The severity and duration requirements can only be proven by obtaining proper medical evidence, as medical evidence is key to any successful Social Security Disability claim.  Social Security cases are often built and won on the strength of the medical records provided by a client’s treating physician.    Therefore, detailed progress/treatment notes, an accurate accounting of your patient's subjective complaints, referrals to specialists, and referrals for objective testing are necessary to build a winning claim. Your treatment notes are an important part of building the strength of your patient's case.  Consistent treatment should be documented with detailed narratives that include the following: specific dates of treatment, your diagnosis, the nature of your patient’s illness, its etiology, severity, and to what degree the impairment limits your patient’s ability to perform day to day activities, function on a job, and/or maintain full time employment. For example, if your patient has COPD and experiences severe dyspnea, chest pains, wheezing, and fatigue upon minimal exertion, indicate all in your treatment narratives.  Further indicate that medium and heavy exertional level activities are not recommended for your patient, and document specific functional restrictions and/or precautions that your patient should exercise on a daily basis.   Also, note why your patient should not partake in specific exertional activities.  For example, "due to Chronic Obstructive Pulmonary Disease, my patient’s lung volume capacity is severely compromised.  My patient should not lift any weight over ten (10) pounds frequently; never climb ladders; never walk for more than five (5) minutes; avoid vacuuming, dusting, mopping, and standing for more than thirty (30) minutes at a time; avoid all exposure  to dust, chemicals, or other environmental hazards."  Also indicate what adverse effects your patient will experience if he or she partakes in any of the restricted activity Your patient’s subjective complaints are extremely important to record upon every visit to your office.  Often, subjective complaints suggest the true severity of your patient’s impairment and how the impairment limits his or her ability to function.  Subjective complaints of chronic and severe pain should prompt further objective testing, physical therapy, and/or referrals to specialists. The results of objective tests offer concrete evidence that cannot be disputed.  Making timely and accurate referrals for CT scans, MRI’s, and X-rays can strengthen your patient’s case and provide and further confirm your diagnosis.  In addition, timely referrals to specialists and physical therapists document the severity of your patient’s impairment and can significantly increase the chances of winning the claim by indicating your patient’s need for ongoing care and treatment.  With the proper referrals, your patient can build a well documented treatment history, which will in turn bolster your patient’s credibility and increase his or her chances of success.  Moreover, timely objective testing can show permanent impairments, helping to satisfy both the severity requirement and the twelve (12) month duration requirement.  For example, frequently a patient who suffers from severe asthma and/or airway restriction disease is referred for a  Pulmonary Function Testing (PFT).  The results of an initial PFT may only show a mild impairment.  However, over the course of time, your patient's complaints and symptoms may worsen requiring you to refer them for further testing.  Subsequent tests can document how your patient's illness has progressed from tolerable to disabling. Often times, physicians note that their patient is applying for disability benefits, but do not indicate whether they have observed whether their patient is disabled.  Therefore, your observations of how your patient’s impairments affect them should be documented, as well. For example, noting that your patient walks with a limp, experiences frequent falls, has difficulty getting on or off of your examining table, was short of breath walking a short distance, heard voices, could not focus during your exam, could not walk from the waiting room to the treatment room without assistance, winces in pain to your touch, or requires assistive devices to ambulate, can benefit your patient’s claim. When your observations are consistent with your patient's subjective complaints and objective test results, the strength of your patient's claim increases substantially. Moreover, completing simple questionnaires or residual functional capacity (RFC) forms indicating how your patient’s impairments limit their ability to function can be invaluable to your patient’s claim.  Residual Functioning Capacity (RFC) forms and/or Medical Source Statement (MSS) are of great importance to any Social Security disability claim.  The forms help Social Security to evaluate the functional limitations caused by your patient's impairments by giving us insight into how those impairments limit the ability to perform work related activities.  The form consists of a list of physical or mental activities allowing the treating physician to assess their patient's ability to perform work related activities by indicating how the patient’s ability to function is limited by his or her impairment.  More importantly, the form contains sections that allow you to further comment on your patient's limitations in a brief narrative.  In a sense, the form gives you an opportunity to be present at your patients hearing. A supported RFC form completed by you may be the most influential piece of evidence in the case and may actually determine whether your patient will receive the benefits they need.  We know completing forms and copying records for legal matters are not a primary concern. However, because your assistance can be the deciding factor in whether your patient will obtain Medicare/Medicaid and the cash benefits needed to afford transportation to your office, helping patients with their Social Security disability and SSI cases is different. The Social Security Administration must consider all medical evidence of record in your patient's claim including your records and opinions, and give great weight to all evidence submitted by you, the treating physician.  Therefore, your observations, recommendations, referrals, and treatment plans are crucial in assessing your patient’s case and achieving the favorable outcome your patient needs and deserves. ### The Law Offices of Eric A. Shore, P.C. (www.1800cantwork.com) focuses on matters of Social Security Disability and SSI benefits.  They can be reached at 215.627.9999.    ]]> http://www.physiciansnews.com/2012/02/01/help-your-patients-get-the-benefits-they-deserve/feed/ 1 Practical Implications of Telemedicine Credentialing http://www.physiciansnews.com/2012/01/30/practical-implications-of-telemedicine-credentialing/ http://www.physiciansnews.com/2012/01/30/practical-implications-of-telemedicine-credentialing/#comments Mon, 30 Jan 2012 20:03:46 +0000 Physicians News http://www.physiciansnews.com/?p=4569 By Lucia Francesca Bruno, J.D., LL.M., M.B.A. For the past century, information technology has reinvented the familiar and revolutionized the art of medicine.  As health care professionals struggle to keep pace with an ever-changing and consolidating industry, traditional forms of health care have succumbed to modern technology and fiscal constraints.  No longer are patients and providers afforded the luxury of being in the same place at the same time.  Recent developments in patient-service delivery systems have transformed the doctor/patient relationship; paving the way for advances in telemedicine and the credentialing and privileging of telemedicine practitioners.  Inside Look into Telemedicine The Centers for Medicare and Medicaid (“CMS”) defines telemedicine as “the provision of clinical services to patients from a distance via electronic communications.”[1] Although telemedicine is not considered a medical specialty, products and services unique to this practice of medicine often require a costly investment in information technology and the delivery of clinical care by health care providers. Telemedicine seeks to improve a patient’s health by permitting two-way, interactive, communication between the patient and the physician, at a distant-site, for purposes of assessment, diagnosis, and intervention.  Examples of telemedicine include, but are not limited, to the following:  videoconferencing; transmission of still images, and remote monitoring of vital signs. A Past Marred by Obstacles Histori