March, 2009

Let me preface this information with two important facts:

• What I'm about to show you has a serious sample size issue.
• What I'm about to show you has a serious data structure issue

But it's still interesting.  A friend of PCC (you know who you are) asked me whether or not we can judge the efficacy of the flu shot (and the flu shot vs. flumist) using our client data.   That's an intriguing question and, ultimately, the answer is no.  Why not?  Because we have no understanding how much of the flu work our clients do represents all the flu shots given to their patients.  And we have no idea how accurately our clients diagnose and then record the flu among their patients. 

Still, I never fear inaccuracy in either my numerator or denominator.  Igor called into four fairly large practices and we can up with this data:

I'm sure you can see my concerns with the data - this raises more questions than it answers. So, I turn it to you, fair readers. What percentage of your patients had the flu last year?  Is there a difference among those who used FluMist and those who didn't?  What do your rates look like in general - are they 2/10s of a percent like some clients, or 10x that amount like some others?  Obviously, you can share your data with me anonymously.  :-)

As though I haven't spent enough time away from home so far this year, I will be on the road giving what I think are some particularly fun and educational talks.  If you are nearby, you have no excuse to not let me know.  Sign up for the event or let me know if you are free.  I have many long-time friends, virtual and otherwise, who are within walking distance of both!

The first place and time will be Tulsa, OK in late April (the 25th, for me, to be exact).  You can download the brochure and the registration PDFs or visit the OK AAP site.  My topics include Effective Patient Recall Strategies, Chronic Disease Management For Fun and Profit, and Patient Education That Pays.  They are updated versions of classes I've only given once or twice (our Users' Conference) and I really like them. I'll also have a chance to catch up with a few clients whom I haven't seen in a while.  I wonder if Tulsa has changed since I've been there?

Update: due to an unforseen conflict, I will not be officially speaking at the OK AAP event, but attending as a vendor.  I am looking into providing the content I have prepared outside the scope of the event itself!  Let me know if you're going to be there!

I then have one of my favorite events, the Pediatric Practice Management section of the Pediatric Gurus event (May 29-31, Skytop, PA) produced by the Goryeb Children's Hospital of Atlantic Health.  I bring my family and, while I chat away to the unfortunate physicians and staff, my kids and wife are off playing shuffleboard or doing archery at the Skytop Resort.  There, too, I hope to meet a few clients and friends while we eat well. If you are in northern NJ/PA, why would you not go? 

According to the schedule, I am also doing Preventive Care For Fun and Profit (which is suspiciously similar to the Chronic Disease course I'm doing in Tulsa), How To Choose an EHR, and Successful Patient Recall Strategies (see above). Use this PDF to sign up and see me there!

Honestly, I think even my little classes are so good - not to mention the dozens of better ones surrounding them - that I'll consider refunding your $$ myself if you don't get a more-than-positive ROI. Think about that.

I don't like to think about the blog on weekends - hey, we're busy preparing for Nowruz! - but I saw this post from Dr. Russell Libby and had to share it.  I wish I had thought to do a similar calculation, but the credit goes to him:

No question about the "new" math.  If a practice has no Medicaid
patients because the state pays at 30% less than their ins reimbursed
rates and they decide to go after the stimulus $ what happens?  If we
gross $5Mil/yr in a 10 FTE practice and could find enough Medicaid
patients in our neighborhood to reach 20% of our revenues (it would
be impossible to identify them as 20% of our patient population) that
would be, assuming 2500pts and 5000 visits/FTEMD/yr, that would be 
5000  new Medicaid patients and  10,000 visits for the group to have
all of the docs qualify for the EMR money.  (I would consider it a
true banner year if I could find so many new patients and get them in
at such a frequency.)  Assuming that the average  revenue/pt visit is
$110  (taken from the most recent surveys in the AAP database), a 30%
hit on that average ticket would be $330K and that would be on a
yearly basis, so that over the 5 years you got the, let's be
unrealistic and optimistic, $70K/MD or $700K  to the practice, it
would cost $1.65 mil in lost revenue.  I know, too many assumptions,
but the reality is that no matter how you dice it, for those of us
who can't afford to have a large Medicaid patient population, the
stimulus money is not really anywhere near the table.

The OCD part of me wishes to point out a few things:

• I don't think the pediatric average revenue/visit is $110;
• I think the average visits/FTEMD should be higher;
• I think most pediatric practices have some Medicaid already, so their need to increase to get >20% is non-existent or smaller;

BUT IT DOESN'T MATTER. His premise is still completely correct, the nitpicks above actually negate each other (I'm sure he knew that and was trying to keep it simple), and I applaud him for pointing out the issue.  Good work.

I've had a lot of surprisingly hopeful emails hit me referring to all the "free money" docs expect to get as a result of the Obama stimulus package.  Put your cynical hats on, folks, because if you think that the HIT-driven stimulus money as it's designed right now is going to benefit you or your patients, you are mistaken.

First, let's look at the macro-economic issue.  I, and others in this business, feel like the stimulus money will ultimately prop up old-style vendor solutions, none of whom are obviously serving the community well.  Further, tying the $$ to a non-market-driven certification process (c'mon, anyone think it isn't going to be CCHIT?) is going to further drive away the innovation and specialization so needed in this business. This looks exactly like the way we treated Detroit for many years and look what that has gotten us.

Second, let's look at the micro-economic effect.  I can't believe people don't see the problem here.  What do you think is going to happen to the real costs for a new EHR if the vendors think that you're good for an extra $40-70K/doc over the next 5 years?  Do you actually think that physicians are anything more than a conduit through which the money will go from the tax payers to the EHR vendors?  How much of this stimulus $$ do you think will really be found in your margin?  $5000?  $10000 over 5 years?  Is that really even worth talking about, if it leads you to choose the wrong EHR?  

That's crazy.  But it's already happening.

Finally, as pediatricians, you have to take specific care.  Here's something John Canning put together informally for our clients.  Take heed. If you're not 20% Medicaid, you're not getting any $$, it looks like.

Greetings -

Like Chip, I serve on a CCHIT Work Group. My group deals with
Privacy (HIPAA) and Compliance. Our meeting today eventually turned to
the Stimulus package and how it will support IT spending for healthcare
(i.e., EHRs).

We received a copy of a very informative presentation after our
lengthy discussion. It does a great job of summarizing the Medicare and
Medicaid incentives for both physicians and hospitals. I learned some
interesting things about the Medicaid money and pediatricians:

1. In order to qualify for funding, at least 20% of the patient
volume at a practice must be from patients receiving medical assistance
(it doesn't say if we are measuring volume based on visits, people, or
dollars);

2. Each state gets to decide whether or not they will pass on this stimulus money to their Medicaid providers;

3. Each state gets to decide what is required for certification (you must have a certified EHR in order to receive money);

4. There is no indication when the money will first become available, although folks are assuming it will be in 2011;

5. Interestingly, pediatricians only qualify for 2/3 of the federal funding described in the stimulus bill (2/3 of $65,000);

6. I am not clear on how practices that are already using an EHR
would fair under this plan. Some of the wording implies they must begin
using a system in 2010.

All of what I am reporting is based on what is written in to the
bill that was signed by Obama. It's still up to the Department of
Health and Human Services to decide how they are going to actually
implement this. Let's hope they move faster with this program than they
did with HIPAA (it was signed in 1996; the law mandated it go into
effect in 1998, but it didn't really go into effect until 2003).

Cheers!

John 

Ghana was...hard to describe.  Did I "enjoy" my trip?  Not really.  Did I have a "good time?"  That's not what I'd call it.  Would I do it again?  Definitely (with a caveat of needing family support).  It was an overwhelming, rewarding experience that I was priveleged to contribute to, in my meager way. 

I hope to have a photo-essay up soon, but here's an amazing result from the trip.

Meanwhile, Susanne Madden released her Q4 2008 Managed Care Company Rankings a week or two ago.  READ IT.

As promised, before I go to Africa, please find some pediatric data gold.

Below is a graph of the visit rate changes our clients reported comparing December 2007 to December 2008 (I'll do 1Q when I get back) broken down by region and by weekdays in the month. The latter adjustment is important, because any given month can swing standard working days by nearly 10% (or more, in the case of holidays) from year to year, which confuses people.

[Click here or on the image for a close-up.]

What do we learn? Well, if we keep in mind that lower visit rates do not always result in lower revenue, it would appear that a lot of PCC clients are swapping out well visits for sick visits. This is a good thing, imo, but I cannot say whether its the result of a late flu season/light sick season or aggressive preventive care management.

A quick glance at this amazing chart from the NYTimes will give you some possible explanation for the geographic disparity. But, as it may surprise some, New Jersey isn't suffering worse than the rest of the country...

Last fall, Dr. Stoller called me.  "Do you know anyone who can do general repair like light carpentry or electrical work, is pretty technical, likes to take pictures, and can write about the kids we perform surgeries on in Ghana?"  Hmmm, let me think.

Sure, it was a setup, but I am appreciative and quite honored to be allowed, frankly, to participate in Our Chance International's annual trip to Ghana from March 5-15.  Their story is not an unusual one, but a good one nonetheless.  I couldn't pass up the opportunity to help some people who need help in a way that puts things in perspective for me.  My only anxiety, really, is being away from my family for so long...but I understand that I'll be tired enough that I won't notice.

I have no idea how "connected" I'll be in Ghana, so no promises about the blog.  I expect to post some photos and stories, though, and then return to my humble pediatric practice management roots when I get back.