May, 2009

Time to broom out the mailbox.  In no particular order:

• Someone(s) at PCC took the time to update our "How To Write A Financial Policy" article over on PedSource.  Good content.
• Head over to the AMA lawsuit page from time to time.If you participate with Well Point/Anthem, Health Net, Humana, BCBS or many others and you are having trouble getting paid for add-on codes or the -25/59 modifiers, you can file a complaint and get some resolution.  Poke around there.
• Now the Washington Post is starting to wonder if the CCHIT/HIMSS connection is a little too cozy.  As a card-carrying member of one of the CCHIT workgroup committees, I fully support some significant chunk of what CCHIT has tried to do.  50%? 70%? 40%?  I don't know, but it's big.  However, I also share many of the concerns that some industry watchdogs outline, and the Obama-bucks are only making things worse.
• The AMA, whom I usually critique, is at least helping physicians prepare for the change to ICD-10.  You can attend their teleconference and ogle their presentation about ICD-10 prep.
• I've been speaking to 5 practices, lately, about starting some flavor of concierge pediatric practices!  I'm thinking of putting together a resource site for them - mailing list, documents, etc.  Any interest?  Here's another article about a practice who is living the dream.  Thanks to histalk2.com for spotting it.
• Did I mention that our summer practice management and coding event in Orlando is now officially endorsed by the AAP?  No?  Well...it is!  Sign up, space really is limited.
• If you're not reading the Pediatric Inc. blog, start now.  Sure, he flatters me all the time, but that's not nearly as important as his great content.  I won't go on-and-on about why I like it except to say: he hits the nail on the head over and over again.  Required reading, imo.

I have written here extensively about the various "scheduling based codes" and their usage - or lack of usage - among pediatricians, but have made the mistaken assumption that most of you reading here actually have extended office hours.

It is this pediatric practice management consultant's position that if you are not offerring office hours to your patients outside standard working hours, you're not only doing your patients a disservice, but yourself as well.

Why?  Because so many of your parents are from families where both parents work or from single parents who work.  And making them come to your office in the middle of their work day adds another variable to the mix which just might - and often does - push them over the edge into not coming into your office.  I hear so many complaints about Medicaid patients not coming in for their visits...how many of them simply can't afford or are not allowed to leave work?  

It's also been my experience that many of the practices who complain or worry most about the minute clinics are the ones who don't conciously recognize the single thing the clinics are better at: access.  

So, here's some good data from the primary care arena.   A hospital expands its hours and sees volume jump.  To quote:

"People really don't want to leave their jobs and come to our offices [during their work hours]," said Dr. Paul Whelton, chief executive of Loyola University Health System, parent of the medical center. "Physicians are making themselves more available. We need to be much more user-friendly.

Here's a telling line:

The American Academy of Family Physicians said 42.4 percent of the doctors it surveyed last year provided "extended office hours." 

I draw two and a half conclusions from this:

•  I'll bet that the AAP has no data about their members and how many offer extended office hours.  Sad.  Someone prove me wrong.
•  Presuming that pediatricians are in the same ballpark (they might even be worse), the implication is that an immediate change you can/should make to your practice to distinguish you is to offer those pre-9am, post-5pm office hours!  And you get paid more, too. 

Am I allowed a deep sigh?

I might be the first person to actually blog during his CCHIT Workgroup meeting, but it really isn't taking much double-tasking to do it, as it's a cut-and-paste.  From CCHIT itself:

CERTIFICATION COMMISSION APPROVES LATEST CRITERIA

Plans Program Changes to Meet New Federal Needs

CHICAGO – May 19, 2008 – The Certification Commission for Healthcare Information Technology (CCHIT®) today announced that it has approved final 2009-2010 criteria for certification of Ambulatory (office-based), Inpatient (hospital-based), and Emergency Department electronic health records (EHR), and for its newly developed stand-alone Electronic Prescribing certification.  The Commission also approved updated criteria for the Ambulatory add-on options in Child Health and Cardiovascular Medicine.  Besides the detailed criteria and test scripts, the Commission will publish a companion guide mapping the criteria to the characteristics of a qualified EHR as described in the American Recovery and Reinvestment Act (ARRA).  The materials will be published on May 29 at www.cchit.org.

“Over 200 volunteers have demonstrated their commitment to improving health and care by delivering this extensive body of work, on time as promised,” said Mark Leavitt, M.D., Ph.D., Commission chair.  “We will be offering these certification criteria promptly to the Federal HIT Policy and Standards Committees, along with data from our four years of experience certifying health IT, as the Committees race to meet their tight deadlines.”

The Certification Handbook, containing the policies of the Commission’s certification programs, is undergoing a significant revision to take into account the expanded applicability of EHR certification under ARRA.  Changes will include a more extensive verification of successful implementation and use of commercial products, as well as piloting of a new program to inspect and certify EHR technologies-in-use that will accommodate a wider variety of development and deployment models.  The Commission has also formed a sub-committee to research usability measurement.

Regarding the opening date for vendor applications to achieve 2009-2010 certification, Dr. Leavitt noted “according to the recently released Program Implementation Plan for ONC, their Draft Rule – which includes standards and certification criteria -- must be submitted to HHS by August 26, 2009.  We will defer launch of our 2009-2010 inspection programs until we have reviewed that material, in order to ensure conformance of this program to ARRA incentive requirements.”  The Commission will release the updated Certification Handbook and announce further details regarding application for 2009-2010 certification during June or July.

C Sue Reber

Marketing Director, CCHIT
Certification Commission for Healthcare Information Technology
503.288.5876 office | 503.703.0813 cell | 503.287.4613 fax
hidden@email-address

Now, I am still convinced that the CCHIT/HIT stimulus package is almost worthy of being called a scam.  I am not alone. But we have done a lot of interesting work on the Child Health group and I'm impressed with some of the results.  Pediatricians should be aware of where the market will be driven.

2009 has been the year of billing service pain.  Right now, Igor and I are talking to no fewer than five pediatric practices who are suffering at the hands of bad billing services.  Here are some of the things I've seen and heard recently:

•  A billing service tells the doctor outright, "We only submit your claim one time.  It's not worth it to us to followup after that.  It costs us too much."
•  A billing service slides a clause into one of the annual renewal agreements forcing the practice to submit all claims/bills through the practice or force the practice to pay the billing service anyway, as though they had done the work.  In other words, if the practice wants to bring the business in-house, they have to wait just like a bad HMO contract.
•  A billing service that slipped in a three year forced agreement.  If the practice wants to leave the contract early - even a month early - they have a $40,000 penalty.  Get this, though: as written, if the billing service leaves, the practice owes $40,000.  Really.  Typo?
• A billing service who promised the world to a startup office but couldn't even get claims out the door for the first three months!

Why are so many practices willing to sign control of their money and success over to entities who have less and less interest in doing what you expect? Lately, I've asked each of these practices for a definitely list of exactly what services the billing service is expected to provide (who posts what, how much followup is done, etc.) and not one of the practices even really knows!

Crazy.  

I have a theory for why things have gotten so bad.  Here's a graph of what I see happening:

In the good ol' days, the billing services did a lot of work.  All those paper forms had to be filled out and filled out differently.  And followup was tough, but families understood the billing process.  So, the initial amount of effort the billing service needed to collect money was significant.  Followup was not really much more difficult relative to the other work, so it was completed relatively well.

Now, however, with electronic claims making the initial dollars exponentially easier to collect and the HMO mess making that last 10-20% of the dollars a lot more difficult to collect (think: high deductibles, secondary insurance, etc.), the billing services are much more focused on the easy work.  Who can blame them?

This leads me to the conclusion that there is a real place in the market for a pediatric specific billing service, one that tracks down money as though it was their own.  Hmmm...

And here's an idea that at least two other vendors have caught on to: if you go out and BUY a billing service, you can lock those users into using your EHR!  Think about it - you're getting paid crazy money already to submit claims (6-10%!) and their contract with you means they can't leave even if they want to.  So, they need an EHR...you simply tell them that it's your way or no way.  

I know of two practices who are in this position right now, if you think it can't happen.

Your billing service nightmares welcome here.

Today's first important alert comes from Siouxsie, who was kind enough to forward the official list of ICD-9 changes for 2010.  Pediatric offices should read them carefully, as there are some doozies in there.  New codes for Colic, Irritability, Impulsiveness, and Nervousness -- sounds like me while coaching farm league.  There's a fascinating set of codes for "Activities" like the E005.3 (Activities involving trampoline) or E007.5 (Activities involving soccer).  My favorites might be the E018.3 or E019.1, look them up. 

Note that there is a series of revised codes that affects pediatricians (V15.86 [Exposure to lead], V65.11 [Pre-natal consult], etc.) and these codes go into effect in fiscal year 2010, which is actually Oct 2009!

Next, I found this somewhat shocking piece about the relative scarcity of pediatricians.  Or, I should say, the lack of scarcity of pediatricians.  A study by Dr. Gary Freed, who already has the AAP (unofficial) endorsement with his immunization data, concludes that there are plenty of pediatricians in the market and we ought not be priming the pump of pediatric residency.   I'd love to know whether other primary care specialties have the same volume of part-time physicians (we see a quickly growing number of part-time peds in our practices).  One comment in the piece jumped out at me, however:

Medicaid covers the vast majority of poor children and its rates are established on a state-by-state basis, not by national policy decisions. Medicaid rates are lower than Medicare rates. Policy makers can't assume they've fixed the problem of reimbursement for primary care If they only focus on Medicare.

Guffaw. The implication of this comment is that only Medicaid pays less than Medicare.  What a joke - I just read yet another contract from UHC where the practice would receive a ~7.5% increase in their fees...and most of the codes were still below Medicare rates! 

The underbelly of the insurance industry came into view earlier this year in New York.  Here's a great summary, stolen directly from histalk2.com.  Look at the conclusive sentence:

A NY physician, concerned by the number of patients losing their jobs and health insurance, begins offering patients a flat $79 a month fee that covers unlimited preventive visits and onsite medical services such as minor surgery, physical therapy, lab work, and gynecological care. State insurance officials notify him his model is not legal and for sick visits he must charge enough to cover his overhead, which he estimates to be $33. The state insurance officials claim the rules are meant to protect consumers. Hmm … sounds perhaps like the officials are trying to protect the insurance companies, but what do we know?

Insane.  Note that this provider estimates his per-visit overhead costs to be $33.  That seems awfully low to me. 

I don't think that concierge medicine is the solution to the myriad healthcare problems in this country, but there are certainly elements of it that make a lot of sense, especially in the primary care arena.

There must be a stack of 10 data-related posts sitting in my in-box, but you get this cleanup announcement while I run off to coach farm league:

•  It turns out that I will be the keynote speaker for the TN AAP chapter meeting on June 19 in Nashville, TN.  Thanks, Michelle!  The titles of my talks will look something like "Chronic Disease Management For Fun And Profit", "Patient Education That Pays", and "Effective Patient Recall Strategies".  I really like these talks, they are a lot of fun.  Come say hello.
•  Our 2009 Pediatric Practice Management and Coding event in July at Disney is starting to draw some attendees at a good clip.  Get signed up!  There is no better pediatric practice management seminar anywhere in the nation.  Period.
•  I've written about the autism "debate" here, but I stopped because it attracted the wrong types of readers and I don't have time to fight off the anti-science hordes when there are other folks doing it better (like Discover magazine, League of Ordinary Gentlemen, etc.).
•  I continue to enjoy the running blog from SRSsoft.  The two latest (here and here) do nothing to dissuade me from the perspective that the Obama stimulus plan is nothing more than a subsidy for the big software vendors.  SRS is actually at the hearings and raising a hand - keep it up!