August, 2009

I love pediatric benchmarks.  Knowing the real underlying behavior in my clients' offices helps me speak to them and understand them better.  There's a particular joy and insight to finding data that challenges the status quo understanding that physicians have of their own offices.

Here's one, and this is very, very interesting data.  Ask a pediatrician - ask yourself - how many of the kids you treat are up-to-date with their physicals.  When I ask, I usually hear things like, "Well, just about all of them!"  Or, "90% or higher!"  Practices feel like they do a good job getting all those visits in when we know that's really not true.

Not only are getting those physicals done good medicine, they're good for your bottom line.  Most practice I work with have missed thousands of well visits this year.  Yes, thousands.  At ~$100-200 a pop, you can do the math.

Don't believe me?  Don't think you're one of those offices?

Igor and I already broke down active physical rates for our internal benchmarking dashboard our clients enjoy, but we wanted to do something for everyone.  So, here it is.

What "we" did (I say "we" because Igor did most of the work, I just do the heavy thinking, you know...) - we broke kids down into 5 different age groups and then took a look at how many of them were up-to-date with their physicals.  For all the kids over the age of three, it's easy to calculate: all of the active kids who have had a physical in the last year divided  by the total active kids in your practice.

For example, if you count up all the active kids between the ages of 3 and 6 years old who had had a physical in the last 365d, you might find 1500.  If you then count up all the active kids between 3 and 6 years old, regardless of their physical statuses, you might find that there are 2000.  1500/2000 = 75%.  Get it?  Non PCCers can do this easily, in theory.  For kids in the 15m to 3yr category, we looked for a well visit within the last 6 months.  Younger than that, it gets tricky.

Let's take a look at the first part of the results (click on the image for a zoomed in view):

I hope this is easy enough to follow - the blue band represents the mean percentage of active patients in each age group who are up-to-date with their physicals.  The surrounding green bands represent the 25/75th percentiles and the red bands represent the 10/90th percentiles.

So, which percentile are you in?

Are 1/2 of your kids from 7-11 overdue for their physicals?  What scares me the most is the big dropoff for the kids in the 15m-3y range.  More next week.

As you know, we held our 4th AAP-endorsed pediatric practice management event in the middle of our annual Users' Conference at Disney this July.  I thought it went swimmingly, but of course I'm talking the entire time so I don't give anyone a chance to complain.

I thought I'd share some of the results of our surveys of the non-PCC folks who attended.  I'm glad to share the PCC-client results, too, but those are kind of silly :-)

First, specific questions with averaged answers:

Don't get the wrong impression - I'm not leaving any scores out, these are just the only questions with a 1-10 rating in them.  We asked a lot of questions which require non-numerical answers, such as, "Which courses did you benefit from most and why?
" and we learned that every class got named at least two times - hard to tell what the most popular class was.  

We plan to return to Florida - hosted by the University of Miami - in January.  An announcement here shortly.

And back with the promised well visit data shortly, still working on it.  I promise that it's pediatric benchmark data gold.

After today's post, I am going to return with some really cool benchmark data (the sort of topic I prefer), but the news about EHRs is coming fast and furiously. My apologies for the length of the post.

First, from the AAP:

Thank you to everyone who helped promote the Webinar over the last few days. For those who were not able to join, we thought it went very well and the responses from membership is overall very positive. Final attendance to the Webinar was 318!

Since it is August recess, we decided against a formal federal update today, but we did want to share the presentation from last night...  We have posted it to the Members Center Federal Affairs page, and we will be uploading the corresponding audio within the next few days.

Finally, in addition to the questions we covered last night, we are reviewing all other questions that were submitted in advance and via the Webinar, and we will be following up with everyone in the next few days.  Please let me know if you have any additional questions.

I've read the PDF in question and, if you are a pediatrician, I encourage you to get it and read it.  It's a 4 minute read.  It covers the bases.

Next,a great summary of the latest HHS position of certification, CCHIT, etc., from histalkpractice.com:

It's clear from Friday’s excellent recommendations
to HHS by the Certification and Adoption Workgroup of the HIT Policy
Committee that they want major changes made to EHR certification. Some
of the high points:

 

• HHS certification (notice they didn’t call it CCHIT certification) is not intended to be a seal of approval.
• A new certification process should be developed that focuses on
  Meaningful Use rather than specific functionality points (that change
  will let specialty EMR vendors certify their products).
• Certification should include all privacy and security policies that are in ARRA and HIPAA.
• New highly detailed interoperability and data exchange specs should be created.
• “Test harnesses” should be created so that providers can test their own software.
• Multiple certification organizations should be allowed, with NIST accrediting them.
• ONC should define certification criteria, not the organizations performing the certification testing.
• Certification criteria will be updated no more frequently than once
  every two years and certification should be good for four years.
• “Lock down” requirements should be eliminated to level the playing field for open source systems.
• Since Meaningful Use definition is imminent, HHS should create a preliminary certification that would be valid through 2011.
• Interesting quotes: “There has been criticism that CCHIT is too
  closely aligned with HIMSS or with vendors. While we did not see any
  evidence that vendors were exerting undue influence on CCHIT, we also
  understand that the appearance of a conflict is important to address …
  Most vendors advocated for a minimal approach to certification,
  complaining that CCHIT has ‘hijacked their development effort’ and that
  they are developing features/functions that nobody will use.”

The takeaway: if the recommendations are accepted, CCHIT’s role will
be diminished and shared with other certification bodies, none of which
will be allowed to create certification criteria; certification will
move away from a detailed product design to focus instead of how EHR
products are used; and CCHIT cannot shake its reputation for being
controlled by a few big vendors and HIMSS. It’s pretty clear that CCHIT
may well have an ongoing role in the government’s HIT policies, but not
at the level of influence it has enjoyed until now. Finally, someone
says no to HIMSS.

Finally, PCC has been working hard on a series of interview pieces among "connected" pediatricians about these issues.  I won't post the entire article here, but we have some "meaningful" quotes from notables such as Drs. Bill Zurhellen, Andy Spooner, and Mort Wasserman.  Read on!

First, some amazing news.  I understood that it might happening, but I guess it's official: new admin codes:

The American Academy of Pediatrics (AAP) was successful in obtaining new CPT codes for immunization administration. The new codes will replace the 90465-90468 immunization administration codes starting January 1, 2011 to better reflect the work associated with administering combination vaccines.
 
AAP will present valuation recommendations for the new codes during the October 2009 American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) meeting. Final RUC recommendations will be forwarded to the Centers for Medicare and Medicaid Services (CMS) for consideration in the 2011 Resource-Based Relative Value Scale (RBRVS).

I believe this effort is related to the disparity between the payment for a one-antigen vaccine and a 5-antigen vaccine.  Rather, there is no disparity between those payments and perhaps there should be.  

Meanwhile, the AAP has updated its Vaccine Coding Table.  I've hosted my own flavor here (complete with ICD9 info), perhaps I'll update ours.

Siouxsie has given me another AAP Healthcare Reform update to continue our previous announcements.  First, an important webinar:

In an effort to provide detailed information on health care reform directly to our membership, AAP will be conducting a Webinar this Thursday, August 13.

We hope that you will be able to join us. Please mark your calendars and look for additional details in the next 24 hours.

WHO: Open to all AAP Members, though space will be limited.

WHAT: Webinar on Health Care Reform, conducted by AAP Leadership and Department of Federal Affairs staff.

WHEN: Thursday, August 13, at 8PM EST.

WHY: Learn about the status of health care reform and how it will impact children and pediatricians, hear directly from AAP leadership, and to find out how you can help!

HOW: Call-in information, Webinar instructions and additional details will be sent out in the next 24 hours.

Thank you,

Erin Howard
Department of Federal Affairs

I got too busy to post this yesterday, so the official invitation has arrived!  If you are an AAP member and interested in the health care reform debate and how it will affect pediatrics, I urge you to attend.

After receiving my third invite to a $450 "Learn What the ARRA Funding Will Do For You" seminar this week, I've decided to run a piece I wrote for the SOAPM newsletter that was released a few weeks ago.  Of course, you can become a SOAPM member and get these messages (and better/more!) a lot sooner - $30 a year.  Do it.

The American Recovery and Reinvestment Act of 2009 and Pediatricians

By the time this article is published, I will have undoubtedly received three or four dozen requests for information about the “free stimulus money” from the present federal administration.  I am dismayed by the glassy-eyed, wishful looks and expectant tones I hear in these questions, knowing that my response is likely to disappoint most people.  Especially anyone who took Microeconomics 101.

Let's review the offer - the Obama administration's American Recovery and Reinvestment Act of 2009 provides the first ever federal incentives to invest in health information technology (HIT), specifically EHRs.  If your practice invests in a "certified" EHR and shows "meaningful use" of the product, you might be paid!  [Note that, at the time of this writing, neither previous quoted phrase is defined and many industry folks see significant problems with both potential definitions.]  This promise of money has already driven practices I know to bizarre - but expected - behaviors.  Although having the federal government focus on the promotion of HIT is a good thing and it's quite possible that the stimulus money will benefit you and your practice, on the whole it will do little more than more tax payer dollars from your hands and into the owners of the (large) EHR companies.

The problems are many.  First, to qualify as a pediatrician, at least 20% of your patients must be covered by Medicaid.  For many of you, getting to that number eliminates any "bonus" you might get.  Especially when you consider that pediatricians only receive 2/3s of the posted benefits that everyone else receives.  That's right - somehow pediatricians need less money to computerize their records.  It must be that high margin and low volume in all the practices I work with (note the sarcasm, please).

Maybe you're already at 20%  Medicaid or higher.  Maybe you already have your eye on a certified vendor who really understands your pediatric needs.  And maybe you trust your state Medicaid program to distribute the money to you once they get it.  That's all swell.

But it's still not going to save you any money.  Why not?   Think back to Microeconomics 101 and what you learned about  the effect on a market when there is a known subsidy.  Although there are many variables to consider (the elasticity of demand, whether the subsidy is given to the purchasers or producers, etc.), don't you know what will happen in the EHR world?  When the EHR companies know that you will qualify for $40,000 of subsidy money over 5 years, what will happen to the price?  Isn't it more likely that the price pressure will be, in fact, negative?  Will you also follow the lesson learned a million times a day in retail stores that your "rebate" will actually drive you to purchase more than you need?

I believe that this distortion to the market is not going to improve the quality of care in this country at all.  And the race to find a certified EHR is going to find many pediatric offices purchasing inappropriate systems, given the paucity of pediatric understanding among them.  And I am particularly afraid that this subsidy program will mimic the results of agricultural subsidies here in the United States, where the top 1% of recipients receive over 30% of the subsidies - the analog of which is that the hospital-focused EHRs are only going to become more dominant and your experience in the private practice world will become less relevant to them.

Here's what really gets me, though - the average pediatrician generates about a half million dollars in revenue every year.  Some generate much more than that.  The amount of money, at most, a pediatrician might receive from this program is...less than 2% of that?   For most of you, that's a little more than additional well visit every week.  Think about that!  Squeeze in 2 extra well visits every week, and you can have your own stimulus!

Ask anyone who has purchased or sells an EHR  and he or she  will agree: purchasing the right EHR for your practice at the right time is worth far more than the money being offered in the stimulus package.  If your practice isn't ready or you choose the wrong EHR, it will cost you much, much more.

My advice?  If you find the right EHR for you - one that doesn't zap your productivity, one that you're comfortable using, one that understands your pediatric needs - then get it.  Don't even think about the stimulus.  As those among us who have already purchased their right system for themselves will tell you, it'll be worth every penny – just as the wrong one isn't worth it at ½ the cost.

==> Read Newer Articles about Meaningful Use at pedsource.com/ehrmoney

For years, I have unintentionally made the rounds of the pediatric speakers circuit, as many of you know.  I enjoy the public speaking process simply because I learn so much and all of my best "material" comes from either being in an office or in front of an audience.

In all immodesty, I think I give pretty good talks.  Don't get me wrong, I could improve 1001 things (just ask 1/2 the folks reading here), but my data is often quite enlightening and I like to think I'm pretty funny. Funnier than most pediatric speakers, anyway, which isn't saying much.  And it doesn't hurt that the number of people in this country who really can speak well on the matters of pediatric practice management is under a dozen, imo.

As a result, I get a lot of offers to speak, which is both flattering and helpful for my job.  Usually, because so few pediatric organizations have any real budget, I am happy to exchange my speaking effort for, say, a booth at the event and my room to be covered so my family can come with me - freeing up $$ for them to get other speakers or even stay alive.

Over the years, I bet I've spoken for at least 10 of the state AAP chapters, more than a dozen hospital systems, and even the AAP itself.  I think most people reading here have seen me at one of these events and it's always great to meet someone in person for the first time.

But I have a feeling those talks are coming to an end.  At least the CME-related ones.

Over the past few years, I've had some interesting discussions with a handful of CME-producing events about me, my materials, etc., each of which was borne from the changes to the CME rules.  Apparently, with the new rules, anything I produce is verboten for CME purposes simply because I work for a "commercial" interest.  Even though PCC is, perhaps, the sole (or best) source for certain pediatric content in the world, we can't share it with you for CME purposes.  Nor can we suggest to anyone anything that we've learned as a result of working with real doctors.

But it gets worse.  Attached, please find the oral testimony of Dr. Murray Kopelow, the CEO for AACME, the people who manage the CME process.  Read it carefully, there are some doozies in there.  Now, I may misunderstand what I read here and I certainly welcome comments, corrections, and contradictions...but how are these changes going to benefit the education of physicians, exactly?

- With the doubling of CME fees and greater (and let me suggest from my experience: ridiculous and inappropriate) scrutiny of those providing it, I think most small time CME providers are going to bai outl.  The bottom line is that the costs associated with providing CMEs have already moved past the benefit of doing so, as a rule.  Do CMEs really put that many butts in the seats?  In the pediatric world, I don't see it.

The people left will be the giants, the big CME machines.  Is that really what CME wants?

- Why is any content developed with the influence of commercial interests automatically unworthy of CME?  By implication, the rejection of my material means that I'm somehow inappropriately influencing people?  That's not only insulting (I'll get over it), but stupid.

The secondary effect of this position is that the quality of CME speakers and content will drop.  I've been to PLENTY of talks - most of them are really boring.  We've just cut off many of the better performers.

In my instance, there is no other source for some of the material that PCC is able to present.  So where are peds going to hear about it now while also rightfully earning CMEs?

- The definition of commercial, as I understand it, is completely bogus.  I've heard talks by hospital administrators and health systems that were way more biased and potentially harmful than any "commercial" presentation I've witnessed.

Just because someone works for a "non-profit" doesn't mean they don't have an inappropriate agenda.  CCHIT (and those who watch them) suffers the same problem

However, here's the most troubling quote:

 Next month new policy becomes effective that excludes from accreditation any entity that markets, re-sells, or distributes health care products or services.

 Someone correct me if I'm wrong...but doesn't this mean that the AAP will no longer be CME accreditable?  Who will be allowed to provide CMEs any more?  No physician, no hospital, no association - they all market, re-sell, and/or distribute healthcare products and services.  Someone explain how I am mis-reading this?
 

If I read this properly, people like Dr. Rich Lander, Dr.Jan Berger, Dr. Chip Harbaugh, Dr. Joel Bradley (to name only a few of our favorite speakers) - they can no longer give CME courses!

Correct me if I'm wrong...