And take that!!

The National Labor Relations Board is suing an ambulance company for firing a worker. The company fired the worker after she posted derogatory comments about her supervisor on FACEBOOK (TM), from her home computer.

The company says the employee was fired for multiple reasons.

The NLRB says the company violated the employee's rights, and that further derogatory comments from her and other employees were "concerted activity" protected by federal labor laws.

The new and marvelous age of technology.

SGR Cuts for Physicians

Unless Congress intervenes, cuts in December and January will lower the average Medicare physician reimbursement by about 30%. Primary care physicians will see a small increase.

Dropping Medicare rates down toward Medicaid rates will do severe damage to some practices. Given the fixed/variable cost structure of physician practices, short term the only practical cuts are in staffing (and that is tough) and physician incomes. Are some physicians gaming the system? Sure.

Conspiracy theorists believe the administration wants to destroy most private practices and drive docs into hospital employment relationships. This could have some benefits, but could also do severe damage to quantity and quality of care, not to mention many hospitals do a lousy job of managing physician practices. This sort of integration can be done fast or right, but not fast and right.

Yes, we need health care reform. Fast and stupid is not the reform we need.

Added to the Document Archive

Document retention Grid.

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Document Archive

Document Archive

We have started an Internet document archive for seminar handouts, white papers, consulting checklists and much more.

healthcarethinktank document archive

Comparative Effectiveness Research, Gender and Emotion

A key cost bending feature of PPACA (Obamacare) is comparative effectiveness research (see http://www.hhs.gov/recovery/programs/cer/index.html).

This research is designed to apply statistical, economic and clinical analysis to care and treatment to encourage effective care and block ineffective treatments.

It is highly likely, based on current research, the statisticians will recommend less screening and much less treatment for prostate cancer. As my doc says, "almost all old men die with prostate cancer, almost none of them die from prostate cancer." Screening should likely be focused on younger men and more aggressive forms of the cancer.

With men being somewhat nonchalant about such matters, and prostate cancer being something less than a celebrity telethon issue, it is unlikely there will much of a fuss. Money can be saved and the resulting increased mortality will be slight.

At the same time, current recommendations about breast cancer are suggesting a lot less mammography, and there is an uproar.

Breast cancer hits many women, hits many younger women, and the results are horrifying. The blowback from advocacy groups has been and will be fierce.

So can we get past gender and emotion to become more efficient and effective? Whatever sounds good in the abstract, many of us will go with emotion.

Obesity and the Medical Office

Obesity, and especially morbid obesity (1), is a growing problem for the medical office.

Even offices equipped for general practice patients, and largely in compliance with the Americans with Disability Act (ADA), may not be able to cope with patients in excess of 300 pounds.

Waiting room chairs and exam tables may not be comfortable or safe, and scales may max out well below the weight of the patients. Lifting and positioning patients can create major challenges. Imaging units may have special technical and positioning problems.

Also, this is becoming a country of power scooters, and many offices are not really designed to be friendly or accessible to these scooters.

Many morbidly obese have problems with ambulation, and many will have orthopedic issues affecting mobility.

And then there is staff, training should be designed to deal with everything from lifting and positioning patients to sensitivity in verbal interactions.

This is a challenge for medical practice administrators and staff.


(1) usually defined as Body Mass Index of greater than 40, or weight 100% above the ideal, or weight 100 pounds about the ideal.

HIPAA Horrors

This has been a week for HIPAA horrors.

A reporter dropping some trash at a landfill in Massachusetts stumbled on a huge pile of medical records. It seems a former billing company for pathologists who served four hospitals had dumped the records without bothering to shred them. Now the hospitals and pathologists are on the hook – ouch.

Then a psychiatrist on the west coast left his laptop on the back seat of his car, and to his surprise (?) it was stolen, and the laptop contained demographic and billing information on thousands of patients.

Obamacare and PPACA Whistleblower Regs

The Patient Protection and Affordable Care Act of 2009 (H.R. 3590, aka PPACA) includes a number of whistleblower clauses. some are focused specifically on long-term care (which should interest physicians servicing ltcfs).

The broadest provision (Act Section 1558) added whistle blower protection to the Fair Labor Standards Act, referenced only to Title I provisions in the bill (critics wonder why not Titles 2 – 9, but there are other pre-existing regs in the federal (and state) law).

Procedural and remedy sections are tied to and mirror the provisions in the Consumer Product Safety Improvement Act of 2008. These include a 180 day statute of limitations, initial complaints are filed with OSHA, options on litigation venues, a right to a jury trial, and a broad range of remedies. The causation and proof standards are very favorable to the employee, and may be an impossible standard for the employer .

Another Section, 6703(b)(3) creates an additional special responsibility for long-term care providers (on top of numerous other reporting regulations) to inform all officers, employees and contractors of mandatory reporting and whistleblowing situations.

Section 6105, specifically focused on long-term care adds a mandatory complaint form for each nursing home (more paperwork, yippee!) and a prohibition against retaliation. Each state must develop (another) process to track and investigate complaints.

Employer “gag order” policies are voided by employee free speech rights, although “gags” related to HIPAA privacy and related issues would appear to remain valid (whistleblowing should be done through government channels therefore not violating HIPAA regs).

Employers may not use mandatory arbitration clauses to bypass or void these statutory rights.

Violating HIPAA at the Speed of Light

Rarely does a week go by without a story of how "social media"** have caused problems for an employer, often because of posting confidential information, photos or just nasty comments about some phase of the business operation or co-workers.

In health facilities the stakes are much higher.

Now is the time to develop policies and educate the staff, BEFORE something bad happens.



** Facebook, MySpace, Twitter, and of course email is also a problem.

IDS - Wave of the Future?

Among those who ponder the technical aspects of health care reform, there is strong sentiment for more use of Integrated Delivery Systems (IDS) in delivering health care.

This is hardly a new concept, but it may well be the concept of the future.

The first big IDS wave occurred in the early to mid-90s, as physicians and hospitals tried various medical service organization (MSO) models; essentially the hospital owned the physician practices. Many of these deals were disasters, some worked, some evolved into something that worked.

The idea is that if a central entity (an insurer, a hospital, or a hospital network) owns and coordinates services there will better care coordination and cost savings.

The successful integrations so far have largely focused on family practice, internal medicine and ob-gyn (the OBs assistance with malpractice premiums and 24/7 coverage issues).

An interesting change is surfacing, the acceptance of specialists and surgeons into IDS models. Historically there has been a great deal of friction between these docs and the hospitals.

Why the change? Fear of dire economic consequences of staying in a traditional group practice model.

Preliminary numbers from the 6/30/2010 residency class is that for the first time, a majority may opt for IDS employment rather than group practice. There are also reports that young docs are more concerned with life balance issues than previous generations.

So, any problems?

Some hospitals are bad at managing physician practices, physician contracts must be structured carefully, physician productivity sometimes drops off with a steady paycheck, and the process of merging practices and/or converting ownership is a great deal of complex work at no small cost. Also, making this work in rural areas is tough.

Biggest question, will IDS on a large scale really cut costs? Or just reshuffle the deck chairs?

Yes - No - Yes - No - Maybe

Medicare Fee Ordeal - Continued

As of today the Senate has passed a six (6) month patch to counter the Sustained Growth Rate formula cuts.

The House will consider the patch next week, and is likely to pass the necessary legislation.

CMS contractors will process claims from June 1 forward - someday.

Stay tuned.

FTC Red Flags Delayed Again

The Federal Trade Commission has delayed the "red flag" identity theft rules for (most) health care providers. The rules originated in the Fair and Accurate Credit Transactions (FACT) Act of 2003.

The act defines most medical providers as creditors.

The new effective date is January 1, 2011.

Stay tuned.

Medicare Reimbursement Game of Chicken

As of June 1, 2010 the SGR reimbursement cuts are in effect.

Or are the cuts really in effect?

The House acted before the Memorial break, but the Senate did not.

Many practices will hold claims for 10 days to see what happens.

This is not way to manage a health care system, and does not bode well for the future.

Sustainable Growth Rate fiasco

Congress left for a two week vacation and the SGR formula goes into effect April 1.

Except......

Apparently CMS is going to hold claims (again) expecting Congress to return and do another patch of the system

This is the roller coaster theory of health care reimbursement. Hang on!

A New Era 3/21/2010

An Editorial:

The passage of the health care reform bill is a major milestone for U.S. health care services. With passage, we will need to unravel the bill and the real story and prepare for the intended and unintended consequences of this massive effort.

The legislation is neither as bad as the Republicans make it out to be, not as fabulous as the Democrats claim. The bill changes the health care system to an amazing depth and breadth, and despite the proclamation of economists, politicians and policy wonks, we do not really know the full impact of the bill.

Reform is needed, we will soon be hitting the point at which employers have trouble providing health insurance to employees at an affordable price, the alternatives being dropping coverage or taking more from employees pockets.

President Obama will be hammered by the political right for going too far too fast, and by the progressive left of his own party for being timid. The left wanted a single payer system, was willing to settle for a public option, but left the table with only hope reform will be revisited, as it will.

The amount of misinformation, over generalization and plain old hot air tossed around during the debate make a calm analysis difficult, and will leave citizens and patients confused and alarmed, probably more than required. The bill is full of slow phase-ins and long transitions as we attempt to turn around one-sixth of our economy and attempt to attain several seemingly contradictory goals.

A great deal of the debate has focused on the budget impacts, and specifically the positive or negative impact on the deficit over a ten year span. The bill is full of wiggles and gimmicks, and as the vote drew near the Congressional Budget Office (CBO) estimated a positive deficit impact of about $140 billion in ten years.

Truth be told no one has any real idea what the bill will do to the deficit over ten years. Anyone who has studied the history of Medicare and Medicaid knows the legislative budget estimates tend to melt in the face of annual politicking and lobbying.

There are problems needing immediate attention. State budgets, hammered by the recession will have to be cut Medicaid benefits, a backwards step. Medicare physician reimbursement formulas, problematic for a decade, are being patched again while Congress dances around a permanent solution. Private insurers and employers will have to adjust quickly to new regulations and cost structures. Changes in Medicare are inevitable.

We can improve coverage and contain cost, but the reforms have to be constructed so carefully it is unlikely any political process has or will do so.

Now we know when the journey begins and the direction it is going. The details will be tough to work out, and there are many battles ahead, but decision making improves as certainty increases. We may get a good place, but not without many bumps and bruises.

A Terrible Story

A pediatrician in Lewes Delaware has been arrested on suspicion of hundreds of incidents of child abuse.

This is a good time to remind physicians about being alone in an exam room with patients, it is almost always a bad idea, especially when the patient is a child or a member of the opposite sex.

More as details develop.

While Rome Burns Nero Fiddles - Health Care Edition

While the House and Senate were trying to overhaul the entire health care system, key Medicare regulations were left in limbo. Those provisions are still in limbo.

Medicare physician reimbursement based on Sustainable Group Resources (SGRs) have been controversial and generally considered unworkable since being passed. The solution has been an annual fix rather than a permanent fix. The House bill had a permanent fix, but went nowhere.

As a result of not being fixed, some physicians will see draconian cuts in Medicare reimbursements as of March 1. Primary care docs will see a small increase in rates. Or there may be a fix, or maybe not.

Physical therapists who provide Medicare services are now subject to a cap, amounting to rationing, for elderly patients. This capping system was instituted in 1997 but an annual fix has prevented implementation. Now that too is in limbo, and therapists may be “donating” services in 2010, while waiting on an answer. If the cap remains, services will have to be rationed..

Seniors are very dependent on various forms of therapy to regain mobility and self-sufficiency after fractures, surgeries and strokes. Would we prefer nursing home placement instead?

If health care reform enlarges the role of the federal government, and this is how the feds do business, this could prove interesting.

The Feds are Coming

After 8 years of lethargy the Department of Labor is gearing up to vigorously enforce both wage-and-hour and OSHA regulations.

The wage-and-hour regs are complex and widely misunderstood. The OSHA rules are better understood but often ignored.

Details on both topics will follow.