Confessions of a Pediatric Practice Consultant

A call went out on SOAPM last week looking for personalized patient recall letters.  I've looked at hundreds over the years, so I asked for volunteers.  I immediately heard from the wonderful folks at the Child and Adolescent Clinic in Longview, WA, who allowed me to rifle through their hard word and share it here. 

Sure enough, CAC (as we know them) has dozens of condition-specific letters that they send to patients.  In addition to the usual well visit suspects, they have very specific letters for:

• Anxiety Disorder
• Bipolar Disorder
• Depression
• Diabetes 1 + 2
• Down Syndrome
• Hypertension
• Hypothyroid
• ODD
• Autism

There are consistent patterns throughout the letters, such as this introduction they send to the parents of their 12 year olds:

As the parent of a pre-teen you know that there are many emotional and physical changes that your child is experiencing. There are many things to do to help your child prepare for the exciting years of middle school! There are new health behaviors for them to learn and roadblocks to healthy growth and development that must be overcome.

Or this, from the ADHD letter:

The pediatricians of Child and Adolescent Clinic are dedicated to providing comprehensive medical care to your child with ADHD. ADHD is one of the most common chronic conditions of childhood, and effects 4 - 12% of school-aged children. It is a condition of the brain that makes it difficult for children to control their behavior. Effective medical treatment is available but must be carefully and closely monitored. Each child with ADHD has different needs and those needs change from school year to school year. A treatment plan that works for one child may not work for another.

Each introduction has its strengths, but I like how they place the practice in the position of being empathetic and providing a medical home environment.

The letters then proceed to a description of the services that CAC
believes are important for each child and then a call to action
for the parents to follow. Textbook blueprints. If I could amend
these letters, I'd pepper the child's name throughout, making them
even more personal.

Without more preamble, here are three good ones to start.

---

12YO Letter

As the parent of a pre-teen you know that there are many emotional and physical changes that your child is experiencing. There are many things to do to help your child prepare for the exciting years of middle school! There are new health behaviors for them to learn and roadblocks to healthy growth and development that must be overcome.

Part of this preparation should include a Well-Child evaluation and physical examination prior to entering middle school. At this appointment the pediatrician or pediatric nurse practitioner will:

* Evaluate physical health
* Assess learning readiness and behavior concerns
* Review your child's immunization status with regard to meningitis and second chicken pox vaccines. This is the first year Washington state REQUIRES these vaccine prior to entering 6th grade
* Prepare sports participation forms, if your child is planning to participate in school sports
* Complete school required individual health plans if your child has a chronic illness such as asthma, diabetes, seizures, etc.

Now is the time to schedule a Well Child-Preteen appointment, when children are out of school on summer vacation. As the summer wears on, the availability and flexibility of appointment times becomes more challenging. We look forward to working with you to help your child toward a healthy adulthood. Please call (XXX) XXX-XXXX to arrange you child's well examination.

---

ADHD Letter
Note the mention of the flu vaccine at the end - every time you communicate with your patients, it's an opportunity to tell them something again. New hours? New doctor? Flu season?

The pediatricians of Child and Adolescent Clinic are dedicated to providing comprehensive medical care to your child with ADHD. ADHD is one of the most common chronic conditions of childhood, and effects 4 - 12% of school-aged children. It is a condition of the brain that makes it difficult for children to control their behavior. Effective medical treatment is available but must be carefully and closely monitored. Each child with ADHD has different needs and those needs change from school year to school year. A treatment plan that works for one child may not work for another.

Our goal is not only to control ADHD with medicine, but to improve your child's quality of life so that he can go to school everyday and be successful. Most children who receive treatment for ADHD based on a long term management plan get along with their parents, siblings, teachers and friends, improve their grades, become more independent with increased self-esteem and decreased disruptive behaviors. We would like to give you the tools, education and medication that will allow your child to reach these goals.
We recognize that parents are the principle caregivers and the strength and support for their child. Parents know their child the best and over time they usually become experts concerning their child's abilities. We will always respect your knowledge and opinion as a parent. Our role as pediatricians is to share accurate and complete information regarding your child's condition on an ongoing basis. This is best accomplished by an extended visit every three to four months, called an ADHD Review Visit. At that visit we will review and update the long-term management plan including adjustment of medication.

Our records indicate that your child is due for an ADHD review visit. We look forward to continuing to provide your child with quality ADHD care. Although your child may have had a recent Well Child examination, the ADHD Review Visit is a separate appointment. Please call the Child and Adolescent Clinic a (XXX) XXX-XXXX this week and make an appointment for your child's ADHD Review Visit.

FLU VACCINE IS NOW AVAILABLE. BE SURE TO GET YOUR CHILD'S VACCINE WHEN YOU COME IN FOR YOUR REVIEW VISIT.

---

Flu Recall 1

A review of your family's medical records shows that one or more of your children may be in a high risk group for complications of influenza. The Center for Disease Control and the American Academy of Pediatrics recommend flu vaccine for all children over 6 months of age. Influenza can be especially dangerous in children with certain risk factors including:

CHILDREN 6 - 36 MONTHS OF AGE
CHRONIC DISEASE SUCH AS ASTHMA, RECURENT CHEST INFECTION
METABOLIC DISORDERS
DISEASES OR CONDITIONS THAT CAUSE DECREASED IMMUNITY
OLDER SIBLINGS OF INFANTS LESS THAN 6 MONTHS OLD
SIBLINGS OF CHILDREN WITH CHRONIC CONDITIONS

If it is time for your child's next well exam, it is a good idea to give the flu vaccine at this visit. Please call our office at (360) 577-1771 if you need to schedule a well visit. If your child does not need a well child visit, please plan to attend one of our FLU VACCINE CLINICS.

SATURDAY CLINICS 9:00 am - 1 pm NOVEMBER 8 & 15, 2013
TUESDAY/WEDNESDAY EVENING CLINICS 5:30 - 8:00 pm NOVEMBER 11 & 12, 2008
We will bill your insurance plan for the vaccine. PLEASE HAVE YOUR CURRENT INSURANCE CARD WITH YOU AT THE TIME OF THE VISIT. We look forward to seeing you and to helping you protect your child against influenza.

---

Excerpt from Flu Recall 2

Our records indicate your child has been seen for one of the following diagnoses in the past 2 years. This places your child in a HIGH RISK category and we invite you to come in to recieve this child's flu vaccine.

PLEASE KEEP IN MIND WE MUST FIRST PROTECT OUR HIGHEST RISK PATIENTS, THEREFORE, UNTIL OUR FULL SUPPLY IS RECEIVED, WE ARE ONLY ABLE TO IMMUNIZE CHILDREN AGES 3 - 18 YEARS WITH THE FOLLOWING ILLNESSES ONLY.
Autism Prematurity Cystic Fibrosis
Down Syndrome Diabetes Type I
Moderate Persistant or Severe Persistant Asthma

[Updated with the new Excel version.]

Welcome to the free 2013 RBRVS Calculator. 

As you may know, the AMA won't let anyone provide a free RVU calculator that includes CPT codes due to their CPT copyrights. In an abundance of caution and, because in our unhappy experience, the AMA interprets its rights (in our opinion) overly broadly, we created this tool for those of you who have a CPT license that allows for a use such as this. In theory, that should mean any practice that submits insurance claims.

To make a long story short, you can use this spreadsheet with the data that you can download from CMS to make a fairly sophisticated RVU calculator in about 5 minutes.

What does it do? It allows you to choose your CMS-driven location, set a Medicare Multiplier, and then, on a code-by-code basis, determine your pricing level. If you then take the time to include your code volume and pricing, it will determine your practice's FACF (i.e., how much you charge, on average, relative to Medicare). If you then provide your payment information, it will compare it to the Medicare fee schedule for you.

As of this writing, I have created an OpenOffice version.  The Excel version is in testing finished.

How does it work?

1. Download one of the above spreadsheets.
2. Head to CMS and download the 2013 RVU zip file. (This link brings you to the January 2013 release; be on the look out for newer versions.) You have to agree to the license and usage rules from CMS, of course.
3. Extract the PPRRVU13_V1226_UP0.xlsx file from the zip file. Yes, I think it's completely lame that our federal government uses a proprietary format for this data, especially one (the new .xlsx) that not everyone who even owns Excel can open. Grrrrr.
4. Cut and paste the entire page of data from the PPRRVU13_V1226_UP0.xlsx file into the tab marked "PPRRVU13_V1226_UP0" in the RVU Calculator spreadsheet. Don't panic if it seems to freeze for a minute, it's a lot of data.
5. Choose your locality with the pulldown menu. Pick a Medicare Multiplier. Then, enter some CPT codes in column A. Gasp in amazement.
6. Put some unit volumes, prices, and payments in and watch what happens. Any field marked in a light blue-gray is a place where you can enter info.

 

I'd love for some guinea pigs to try this out and tell me what doesn't work. PCC clients, natch, can do this already with our reports, so I want to hear from the rest of you :-)

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[01/03/13 Update: with the release of our latest episode, we have the Google Community page running nicely and the podcast is available both directly and in itunes (search for "pediatric practice management" or click there).  Please subscribe as we expect to deliver a new episode every two weeks.]

 

It's alive and it's official, even though it could still use plenty of polish.

The biweekly episodes of the Pediatric Practice Management Media Cast are now also delivered in podcast form as well as video form, making it easy for you to listen to us while working out or in your car or while fixing dinner.  No need to stay glued to a computer screen.

We believe we have also found a permanent home for the video postcast, and that's in our new Google community.  Ideally, you can subscribe to feed you prefer most, video or audio.  We expect to have the podcast added to the iTunes list any moment now, though it may be delayed until the 28th.

Brandon and I have already shot the 3rd episode (Billing Services, Pros and Cons) and the 4th will probably focus on what I'll call Front Desk Benchmarks, per the request of a big fan. Episode 3 is scheduled to air during the first week of January.

Keep your comments and requests coming!  We are delighted to focus our attention on the subjects you want to hear about.

To recap:

To watch the videos and subscribe to updates, head to Pediatric Practice Management Media Cast Google Community.

To listen to the Pediatric Practice Management Podcast, which is the audio version of the podcast (and you don't need to see our ugly mugs), head to the Pediatric Practice Management podcast page.

Please join the community!  More soon.

 

Brandon Betancourt and I have had hours of conversations over the years, both in person and over the phone, in which we undoubtably solved all of the world's problems.  At least the pediatric practice ones.

However, we never wrote any of it down. All that amazing information is lost to the wind.

Things have changed, though.  Brandon and I have agreed to record our conversations both on video and as a podcast.  I don't know how helpful it will end up being, but we're going to give it a try.  My hope is to create a stable of topics and guests and create a community of Pediatric Practice Management experts you can both see and hear.

I have much more to say about it - particularly to remind myself not to wear a sweatshirt and check my hair before doing another one - but it's a start. More soon!

A good friend remarked that my blog is a little "stale" these days, and she was right.  I am so caught up in putting out fires these days - ARRA, PCMH, portal design, etc. - that I forget to come back here.

(And, hey, it's a lot of work to take visiting clients out to lunch and dinner!)

Let me give you some insight into the latest fiasco we're dealing with here.  I am going to keep the names of the entities in question redacted because the last time we publically complained about one of them, some of our staff received harassing calls at home from the company.  I'm not joking.

Here's the scenario: a BCBS program in one of the states where we have just under a dozen clients has advertised to its practices that they provide "free, real-time eligibility" functionality.  Our clients have seen this and asked for it.  Because we act as our own clearinghouse and generally provide these services for free, we got right on it.  We love real time eligibility and must deliver it a few hundred thousand times a week to our clients.

But, it isn't so simple in this case.

The first thing we learned is that the BCBS in question has signed an exclusive contract with a particular clearinghouse vendor.  Thus, we can't work directly with the insurance company, we have to go through a third party.  And, surprise!, this BCBS isn't on the magic list of "free claims/eligibility" for this third party.  What?  How can BCBS say one thing and the vendor say another?  It's easy - while there may not be a per-transaction fee for each of the claims...there is a $5,000 setup fee to get started. 

So, free to the clients, but the third party clearinghouse still gets paid.  Maybe you don't think $5,000 is a big deal, but consider this:

•  we already have real-time eligibility connections with this vendor and have for years.  This is just toll charge, the work was completed years ago.
• that $5,000 charge only appeared after we went to BCBS and complained about the $15,000 charge the vendor told us we would incur if we submitted any real time transactions to them through our already existing integration.

It gets even better.

If we do decide to enter into this agreement, both PCC and the client then have to sign exclusive agreements with the third party vendor.  What does that mean?  It means neither PCC nor the clients can use any other clearinghouses to submit their claims or eligibility requests.  PCC already has existing contracts with quite a number of other clearinghouses in different parts of the country.  And our clients use us to submit via the most cost effectice and supported solution.

How is this legal?  How is this not restraint of trade? Two small pediatric practices can't discuss their pricing legally, but an insurance company representing >50% of covered lives in a state can force their physicians to sign an exclusive, expensive contract to get real-time EDI transactions?

ARGH.  And we wonder why health care costs so much here.

Two important resources from my SOAPM friends. 

Part one, from Jose Lopez @ AAP:

SOAPM partnered with the AAP's Childhood Immunization Support Program to
produce the attached poster for AAP members at no charge. Please feel
free to print (11x17 paper) and display it in your practice, we hope
that you like it! Feel free to distribute- we will be posting online
soon. And don't forget to have your practice staff get their flu shots
if they haven't already!

PDF attached herein.

Part two, from Dr. Berman:

As you are aware, there are now CPT codes for smoking cessation
counseling (99406 and 99407).  Since I practice in the "chaw belt" of
the US, this is something I'm starting to use more.  However, the CPT
definition of 99406-7 states the codes should not be
reported when it's the parent/caregiver smoking -- only the child.

As pediatricians, we see lots of kids with recurrent OM, wheezing,
"allergies," etc., where a code for parent smoking might be helpful. 
Certainly you can use 99212-5 as a time based code, but that's only if
you spend > half the visit doing counseling.  In
my practice, typically I'll spend the bulk of my time on the child's
issue (OM, cough) and then spend a few minutes talking to the family
about passive smoke exposure.  That is, I don't hit the 50% threshold on
time.

I've done a few Code Change Proposals for CPT before, so I would be
happy to take this on.  But if y'all think this is not needed, or a
Supremely Bad Idea, please be frank.

https://www.surveymonkey.com/s/X67WC7L

Would you use a parent/caregiver smoking counseling code?   Take the poll!

Do it!

Short of riding the mechanical bulls on Bourbon Street, I think we fulfilled our social requirements at the AAP NCE this week.  I starting making a list of people I got to greet, but gave up after 50.  And it always remains a treat to meet people I've only known virtually - thanks for introducing yourselves.

Click on any of the pictures to zoom in!

It's been too long since I've had a post like this.  Glad to get back to the most important material we share.

A few weeks ago, one of our clients asked us, "According to the new Obamacare rules, well visits aren't supposed to have copays any more...yet, I see them all the time.  Did healthcare reform do anyone any good?"

It's an interesting question.  We know that most of our clients felt like there were fewer well visit copays, but some of our clients continue to see them quite often.  We, of course, like to know how often and to what effect.  So we (meaning, Igor) looked into it.

Here's what he found:

Since Q3 2010, when the healthcare reform laws went into effect, the portion of well visits paid by patients has declined steadily every quarter, presumably as most insurance companies slowly started taking copays off of well visits. It's also interesting that while patients are paying less for well visits, insurance companies are paying about 14% more for an average well visit code than they were in Q4 2010, such that average total well visit payment has gone up about 6% since Q4 2010.

We know that this aspect of healthcare reform wasn't entire responsible for the 6% overall increase in well visit codes in two years. We also know that RVU values increased (thought that process was tied into the reform as well).

This is what he had to say about state-specific results, however, which reflect the percentage of ERISA-based plans (i.e., plans that don't have to follow the new rules) on a state-by-state basis:

It's not an easy trend to graph, but you should be able to pick it out from this (click for more detail):

 

 

Looking at just NJ PCC client data shows some interesting results. In NJ, patients started paying less in copays starting around Q4 2010, but unlike the national average, insurance companies their portion of payments very slowly such that the overall well visit code payment now is not much different from where it was two years ago.

 

We chose NJ, of course, because that's where our originating physician hails from.

Now that the AAP is no longer producing or developing their vital coding and practice management events, we have to rely on others to continue to push out the content that we know is so vital.  I am, of course, biased, but practical, when I suggest that the PCC UC is perhaps the strongest option available to the public (here are the 2012 details), but I'm delighted to announce a third.

CodingCon 2012 Pediatric Track

OK, sure, I'm presenting the pre-conference day and an RBRVS class, but the rest of the conference is divided up between Dr. Rick Tuck and Jen Goudreau.  I'd put them both in the top-5 pediatric coding experts nationally.  Look at just some these great courses:

Auditor Eyes Are on You — and Your Payments Are Secure!

Coding for Your Valuable Time

Coding For Immunizations, Making It Easy - Rick Tuck

Modifiers That Get You Paid!

Protect Deserved Hospital Care Pay With These Denial Busting Moves
- Jen Godreau

...and that's only 1/2 of the pediatric content.

My experience is that even the briefest coding or PM seminar pays for itself quickly when you get quality content like this.   If you don't learn something from the speakers lined up here, maybe you should be teaching the rest of us.

Here is the event attendee brochure.  This should be a great time and help fill the pediatric coding and PM coaching gap.

 

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Here's a PCC client speaking about his localized ACO/hospital experience.  I spoke with him a few times during the process and the message I think we kept coming back to is that the hospital is rarely a pediatrician's friend.

Identifying information redacted.

By way of background, pediatricians (and most primary care physicians) in [City] exist in very small groups, anywhere from 1 to 6 physicians on average. There are a few large groups, but these are the exceptions, not the rule. This is not true in many other parts of the state, where pediatricians by and large are in huge groups, having been bought out by a hospital system or something like that. We have been able to stay small in [City] thanks in part to some of the best payment rates in the country and a fierce sense of independence. (and, for some of us, good business sense and the help of SOAPM, although that cannot be said for many).

For many months, I have been quietly speaking with other pediatricians when I saw them on rounds or in other situations, trying to raise awareness that times are changing, payment methodologies may be changing, and that, whether we like it or not, the ACA is upon is. I felt it was the right time for pediatricians to at least be discussing the best ways to survive and thrive in changing times. Most of the pediatricians I spoke with were not interested in having any sort of discussion, stating that the ACA would be overturned, they were too busy with their personal lives, or that they did medicine, not politics.

Then, we started getting letters[...]. Each of the major hospital systems here are proposing clinically integrated networks, stopping short of ACO formation, but obviously with that goal in mind. I attended the information sessions for some of these and found that there really were no benefits for a pediatrician to participate, as they lacked pediatric resources and I couldn't see where the benefit would come for me. I was also very concerned with the thin deadlines presented to sign up, as it would seem that no decision like this should be rushed.

Our local childrens hospital has never gotten into the business of working hand in hand with private practices, unlike our neighbors in [City2], where many of the pediatric offices are now part of the [Childrens Hospital] network, essentially owned by the hospital system[...] I was approached by my physician relations rep from our Childrens Hospital to have lunch with some new administrators to discuss what they were looking to do in the community in response to the changes in the healthcare landscape. I saw this as an opportunity to be on the cutting edge of change and to at least investigate what might be out there. Through our initial meetings, they were proposing to bring a group of us from private pediatric practice together, not for the purpose of buying us, but to have a series of meetings to talk about the changes coming and look at models as to how we could thrive together and provide the best possible clinical care for kids in [City].

We discussed how they could help us become certified medical homes. We discussed how we could improve care for children with chronic disease, which has been quite fragmented in this area. All in all, there were a lot of positives.

They then asked me to lead this group, as I had the best working knowledge of the issues out there. I tentatively agreed. There would be some compensation involved due to the extra work required on my part. I received a document that would make a contract laborer for them. We had our first meeting before I could have this document reviewed. This first meeting was really just a discussion of who we were and what we were looking for.

In the room were 2 primary groups of pediatricians - (1) those who felt fairly financially stable but were concerned about where the future was headed and (2) the majority of the people in the room, who were desperate for help in the day to day operations of their practices. I invited everybody to join SOAPM and reviewed all the other resources available to everybody through the [State] Pediatric Society, the [State] Medical Association and our County Medical Society. There was a large group missing from the room, and that was most of the pediatricians in my part of town.

In addition, the mission of this group seemed a little different than that had been presented initially. Now, we were to specifically work toward forming a clinically integrated group of pediatricians. Although this had been mentioned as one of the options on the table during our preliminary discussions, it had never been a fait du accompli.

I then also met with someone from the [State Medical Association] who is an expert on issues related to new ways of networking physicians and had a lawyer review the contract labor agreement. It was clear from the agreement, that I was expected to be an advocate for the hospital, which had not been agreed upon previously.

I met with the administrators leading this project again and reviewed my reservations about being expected to advocate for the hospital and that it seemed that even though we had said we would discuss models of care, it seemed as if the hospital had already decided which model it was to adopt.

Finally, they said that I needed to review their master plan document for "population health management". This document looked exactly like what all the other hospital systems had proposed. In thinking about shared savings plans/ACOs, they eventually would have to include the adult physicians from the university, since there is not enough potential savings to be gained from pediatricians alone. It was clear that I was being asked to figurehead a group, but that the real decisions had already been made at the board level.

Ultimately, I have decided to not take on leadership of this group, but to still participate for now. Here are the lessons I have learned:

(1) Hospitals are not your friend. Although there may be some areas where there have been successful partnerships between hospitals and physicians, if decisions are being made at the board level, they don't necessarily have your best interests in mind. The administrators keep talking about how Childrens Hospitals are similar to pediatricians in that they get left out of a lot of decisions that general hospitals make. Not sure this comparison is valid.

(2) Our childrens hospital has never had good town/gown relationships with waves of subspecialists leaving to go out on their own. Consultants they hired to help them with this project and the administrators themselves have said that part of what they want to do with this project is too revitalize their image with local pediatricians, but I don't feel they've done a great job since they were not up front about their master plans from the beginning.

(3) Large organizations are trying to effect cultural change in a very short period of time. It took years for organizations that are being held up as models (Mayo Clinic, Cleveland Clinic, [X] here in [State]) to become what they are and organizations now are trying to do this in 6 months. Artificial deadlines of "you must sign this contract in the next week or be left out" make me want to be left out.

[...]

(5) Use the services of your state medical society - they probably have somebody who is focusing on these issues and can provide you with a great education. Of course, everything I learned I really learned on SOAPM and am so thankful for the discussions here and being able to pick the brains of individuals offline.

(6) One of the scariest things coming out of these new networks that are popping up include the signing contracts with major employers. With what is happening here, if you are not in their special network, employees of those employers can still see you if you are in network for their insurance, but at higher out of pocket costs than if you were also in their special network. Eg. Someone is insured through Blue Cross through the [Hospital] Quality Network ([Hospital] is one of large local hospital systems). If you are a BCBS provider, you can see them, but you are not a member of the [Hospital] Quality Network, they will pay higher costs to see you even though you are a BCBS provider.

(7) Ultimately, I think the hospital wants to buy us out. The counsel for this group, whose husband owns a pediatric practice but for some reason has chosen to not be at the table, did a review of all the ways physicians can join together and their relative antitrust risks. As an aside, she said the least risky arrangement is to be employed by the hospital, "which might not be a bad model to look at".

(8) The relationship between private practices and hospitals is chaging dramatically. Hospital work is such a small part of what I do, but these changes potentially make me very dependent on the hospital's clinical and financial health, not something I'm sure I want to leap into.