I feel your difficulty being empathetic.

During his speech this morning, Cleveland Clinic CEO Toby Cosgrove, MD, was remarkably willing to admit his own flaws. He talked about the clinic's less than stellar levels of employee engagement and told one negative story on himself. When he spoke to a Harvard Business School class, one of the students asked him about his reputation for a lack of empathy. The question really made him think, he said, about how empathy is something of importance to patients that he hadn't focused on.

And then he launched into a slide show of all the recent improvements to patient experience made by the Cleveland Clinic--more windows, free wifi, greeters at the door, sofa beds for visiting family, hospital gowns designed by Diane Von Furstenburg. It struck me that those are all great patient-centered innovations, but they do nothing to make clinicians more empathetic to patients--the b-school student's actual concern.

Dr. Cosgrove's struggles with empathy reappeared during the Q&A. One questioner asked how small and midsize practices (where most of the MGMA attendees work) could provide high-quality coordinated care without the integration and resources of a big health system. Dr. Cosgrove responded by saying that he thinks the trend in health care is definitely away from small practices and toward big employed systems. In other words, you can't do it, so you'll be gone soon. Ouch.

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posted by Stacey Butterfield at 3:00 PM   0 Comments

Jargon of the day

The term "patient-centric" may have only recently appeared on many clinicians' radar, but it's already headed for obsolescence. Kaiser Permanente is working on being more "consumer-centric" and "member-centric" to capture potential, in addition to actual, patients. "We can no longer wait for the patient to show up in our exam rooms," said medical director William Wright.

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posted by Stacey Butterfield at 1:12 PM   0 Comments

Out of the mouths of executives

They weren't the "futurists" who have been popular features of conferences lately, but I'd still put some faith in the predictions offered by the speakers I heard this morning. An MGMA panel included Toby Cosgrove, MD, Gary Kaplan, MD, and William Wright, MD, chief executives at the Cleveland Clinic, Virginia Mason and Permanente Colorado, respectively.

They had a lot of miscellaneous information to offer (strategies for improving quality, maintaining employee satisfaction, etc.) but I found a couple of points on health reform particularly interesting.

All three have electronic medical record systems, and while they think that the technology will have beneficial impact on quality, they say the government's focus on EMRs as cost savers is misguided. "I do not think we've saved a penny so far and we've shucked out hundreds of millions," said Dr. Cosgrove. Dr. Wright also made the point that EMRs will make no difference in quality, either, unless they're used to improve other aspects of care.

So how will health care reform manage to save money? Bundled payments. All of the execs think that bundled payments for episodes of care and outcomes are coming and that they will have a major impact on the way money is distributed within health care. Dr. Kaplan thinks they'll even create downward pressure on proceduralists, when various specialties have to divide the pot. They're so certain about the impending changes that one of the docs described physician-owned hospitals as an effort "to take the gains for the few remaining years left."

Another prediction that might displease physicians was the experts' certainty that minute clinics are here to stay. They advised providers to either embrace the trend or partner with it (Cleveland has a partnership with CVS).

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posted by Stacey Butterfield at 12:53 PM   0 Comments

The annual point when the biz of medicine gets me down.

Now that T.R. Reid and Ezekiel Emanuel and I have hung out (OK, so they lectured and I listened along with 2,000 other people), I like to imagine that I understand a little bit about how they think.

And I imagine they would have been just as depressed as I was with yesterday's session on how primary care practices can make money by going into the imaging business. There were so many wrong incentives involved, it's hard to even count. You can begin with the fact that the lecturer predicts continuing growth in the imaging industry because tort laws (or at least perceptions of them, I would argue) appear likely to continue encouraging defensive medicine.

Then there were the obstacles you would face, most notably the Stark laws. But a good health care attorney can find lots of ways to work around these, the speaker said. Take the example case offered in the session. The anti-kickback statutes prevented this practice from actually providing any imaging, so they decided to go into business buying imaging from the hospital. In other words, as best I can understand, the only thing that changed was that the primary care practice would now send all of their patients to the hospital for imaging, pay the hospital for the service, bill insurers and take a cut off the top.

The story is in some ways an argument for the effectiveness of government-run health care. The setup wouldn't fly with CMS, so it only applies to private payers.

I don't mean to necessarily condemn practices that do this (they're only being good capitalists after all), but when you think about where their profit comes from, it makes clear the defects in our system. The practice's slice must either being coming out of the non-profit hospital's pockets or the insurer's (and thereby all of their premium payers) and represents no actual goods or services.

And despite all the talk of cost-cutting, this isn't an issue that health care reform will probably tackle. Proposals like bundled payments and the medical home could even make such arrangements more convenient, the speaker concluded.

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posted by Stacey Butterfield at 8:29 PM   0 Comments

Improve your patient satisfaction scores for free!

I was going to call this post "ways to be nicer to patients" but we all know nicety is not nearly as compelling a motivation as a bump in pat sat.

So, some quick tips from Meryl Luallin, a consultant and secret-shopper patient who spoke today:

Don't put up a sign at the front desk instructing patients to sign themselves in and wait to be called. It's unfriendly. "If you're short-staffed, short the staff somewhere else," she said.

When you enter the exam room, don't say "What brings you in today?" "How can I help you today?" gets the same answer but sounds nicer.

And lastly, when a patient phones to talk to a physician, staff shouldn't say "He's with a patient right now" because the patient will assume that the doc will call back as soon as he is done with that patient. Instead, try "The doctor usually returns phone calls at the end of the day. Is there something I can help you with in the meantime?"

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posted by Stacey Butterfield at 6:31 PM   0 Comments

Overheard at MGMA

I spend most of my time at conferences attending sessions and (obviously) updating the blog with what I've learned. For reasons I've never understood, most of the other reporters spend their time interviewing vendors of electronic health records (EHRs).

Writing on the computers in the press room gives me the opportunity to unobtrusively eavesdrop on their interviews. They're not usually very exciting, but today I heard something noteworthy--three different EHR vendors told three different reporters the same thing. To paraphrase, "Traffic is down on the exhibit floor, but the people who come by are way more serious about buying." Either they had a secret EHR vendor talking points meeting, or the attendees at this meeting really are shopping for more than free food and pens.

This is sort of contrary to what we heard at the MGMA press conference, which was that members seemed to be holding off on EHR investments until the government better defines "meaningful use" at the end of the year. That was just the impression of MGMA staff, though, so maybe they've missed this new trend.

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posted by Stacey Butterfield at 4:58 PM   0 Comments

Spotted in the exhibit hall.

Could it be the long-awaited medical home?

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posted by Stacey Butterfield at 3:02 PM   0 Comments

More from Emanuel

I just keep coming across more interesting things in my notes from Ezekiel Emanuel's speech.

For example, he described a cooperative program between Starbucks and the Virginia Mason health care systems. Starbucks employees were frequently going to the doctor complaining of back pain (no suprise in an on-your-feet, heavy lifting job) and it was costing the company in medical expenses and sick time. So Starbucks and Virginia Mason made a deal to get these employees the most cost-effective, evidence-based care. In other words, fewer pointless MRIs and more physical therapy. Employees got less medical care but better outcomes. Of course, under the current reimbursement system, the result was less money for Virginia Mason, so they made a deal with Starbucks to get paid a little more for physical therapy to make the overall savings benefit everyone involved.

Not sure if this is a happy story about effective cooperation, or a horrifying example of how dysfunctional our current health care system is.

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posted by Stacey Butterfield at 3:00 PM   1 Comments

Out of context

This quote from a session on communication would make a little more sense in context, but I much prefer it as is. "If the doctors don't want to wear the duck suit, then they don't want to be part of the culture of our group."

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posted by Stacey Butterfield at 1:31 PM   0 Comments

Another reason to get an EHR.

There's been a lot of talk at the meeting about stimulus funding for EHR systems (I've never heard the phrase "meaningful use" so many times), but a session on physician profiling offered a new reason that you might want to invest in an electronic system.

In case you missed it, physician profiling refers to insurers' systems of ranking physicians by cost and quality (but mostly cost) and pushing insureds toward the best-value docs. The insurers make mysterious calculations comparing claims data from your patients to comparable others. Then they give you a star or multiple stars if they find your care to be cost-effective.

But if they don't think you're doing well, and you disagree, you can use data from your EHR to fight back. Although the insurers won't reveal their specific formulas, you can pull data from your system on the patients or conditions in question to prove your case (by searching for migraine codes or generic prescriptions or whatever).

One caveat, though: it's a major undertaking, and the physician profiles don't affect reimbursement, so if you have more than enough patients already, you might not want to bother, the speaker said.

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posted by Stacey Butterfield at 9:00 AM   0 Comments

Does your waiter Xerox your credit card?

At the annual MGMA press luncheon (yes, our entire day revolves around free food), MGMA president William F. Jessee gave us the usual update on the opinions and activities of the group. (See next week's ACP InternistWeekly for full details.)

They are still avidly pursuing their plan for a standardized machine-readable patient ID card, like a credit card for your health insurance. Several big payers--Humana, United Healthcare, regional BC/BS--have signed on, but Medicare is a major stumbling block. The stick-in-the-mud agency, which is also thwarting MGMA's desire for a national health plan identifier and electronic claims attachments, is sticking with paper cards with social security numbers. (How retro!) Jessee was optimistic about Project SwipeIT, though, and said that the plan for 2010 is to "crank the pressure up a little" on insurers that haven't signed on yet.

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posted by Stacey Butterfield at 4:36 PM   0 Comments

Statistics and predictions of the day

Since I can't share my conference-supplied muffin with you all, how about some tidbits of information from MGMA?

From Ezekiel Emanuel: 10% of the U.S. population is responsible for 64% of our health care costs, while 50% of the population spends only 3%.

From Max Rieboldt, a health care CPA: "Within the next 10 years, at least 80-90% of physicians will be employed. We're headed more and more in that direction." One of the major reasons for that? Physicians' insistence on being paid to take emergency call. Hospitals like having the responsibility for call as part of the employment contract, instead of an extra issue to negotiate and pay for, he said.

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posted by Stacey Butterfield at 1:00 PM   0 Comments

All we need is the will.

This morning's featured speaker at MGMA was T.R. Reid, of Washington Post, NPR and new book about health care around the world fame. His speech covered a lot of territory and included some humorous tidbits (Why doesn't French health insurance cover Viagra, according to the country's health minister? Because French men don't need it.)

Anyway, after all his travels, he came to one main conclusion about why the U.S. health care system is different (and more of a mess than) others around the world: our variety of coverage. "In all of the other countries, they've settled on one model for everybody," he said. In contrast, the U.S.'s major achievement is having an example of every possible coverage plan (compare the VA, Medicare, employer-sponsored coverage, and uninsured care), which adds complexity, administrative cost and little incentive to prevent illness, not to mention being unfair.

The good news is that he thinks there's hope for us: "If the U.S. could find the political will to provide health care for everybody, the other rich countries could show us the way."

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posted by Stacey Butterfield at 12:00 PM   0 Comments

No limos, but I did just ride down the hall in a golf cart.

Did you ever wonder who's been eating all that free food that doctors aren't supposed to accept anymore?

It's the medical group managers, from what I can tell. There's also free booze here. But last night, the Denver Convention Center seriously tested our commitment to consuming freebies. Just as the opening reception was beginning, the fire alarm went off. The dilemma: heed the alarm (and the weird burning smell) and leave the building or hit the open bar? I'm sure you can guess the general decision.

The especially brave hooked themselves up at the oxygen bar. Nothing like pure oxygen, liquor and a fire to get the party started.

Note on the post title: I'm not kidding. They actually have golf cart shuttles, as well as a cappella singers and women on stilts pretending to be trees.

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posted by Stacey Butterfield at 10:38 AM   0 Comments

Saving money with limos

Ezekiel Emanuel, senior health care advisor to the White House, wants you to have your patients picked up in a limo. Ok, not exactly, but he did list chauffeured luxury rides as one of the techniques that practices have successfully employed to get patients to show up for their appointments. If the office visit prevents a serious complication or hospitalization, then the limo's actually a cost-saver, Dr. Emanuel explained to MGMA attendees.

He has a lot of plans for saving money in health care, most revolving around the creation of comprehensive medical homes for patients with chronic diseases. (You know the drill--team care, coordinators, patient education, better transitions.) So how do we get there from here? Dr. Emanuel favors a bundled payment system. His model would be a modified fee for service system, in which the cost of a patient's care would be compared to a guideline-based, risk-adjusted estimate of what's appropriate. When a patient's care comes in under that number, physicians get to split the savings.

According to Dr. Emanuel, this system could help give doctors the feedback they want and need and provide incentives to offer quality, not excessive, care. Speaking of excessive, Dr. Emanuel also had an interesting perspective on the much-discussed impending doctor shortage. He does see a need for more primary care, but he doesn't think we are short of doctors overall. If we did fewer inappropriate PCIs and knee replacements, the existing docs would have time to get all the actually needed care done, he said.

Note: Dr. Emanuel was careful to state that he was speaking on his own behalf, not the administration's.

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posted by Stacey Butterfield at 11:33 PM   0 Comments

MGMA: Ill-advised session titles

I'll be blogging from the annual conference of the Medical Group Management Association next week, so it's time for another edition of Ill-advised Session Titles.

After years of study, it has become clear that there are certain best practices for attracting potential attendees' attention. First, resist the impulse to explain your catchy title with a subtitle.

For example, MGMA's "Can't We All Just Get Along? Successful Conflict Management Strategies" is eye-catching, but you can also guess pretty well what the session will entail. How much more intriguing are these sessions?

"Can We Talk?"
"Why People Do What They Do"
"Not All Patients Are Created Equal" and last but certainly not least,
"Execute for Results!" (Who or what are we executing? Aren't you dying to know the results?)

There's also something appealing about undercutting your topic in the title, as evidenced by these two sessions: "Successful Transition to a Hospital-Employed Practice Model (While Maybe Keeping Your Job)" and "Hospital Employment for Radiology: Maybe Not as Bad as You Think." (It's perhaps not coincidental that these sessions deal with the same issue.)

And finally, this session wins our award for best visual image: "Help Your Physicians Wear Their Many Hats." Fedoras, bowlers, ski caps?

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posted by Stacey Butterfield at 9:00 AM   0 Comments

Best of convention hopping

After a whirlwind of conventions, it's time to head back to the office. But, before I go, a few non-clinical highlights:

Most unusual swag: It looks like a highlighter, but one end is a hand sanitizer spray, and the other is lip balm.

Rudest attendee: Raised his hand in the MIDDLE of a session and said, "I don't mean to be rude, but this is a little boring."

Strangest group psychology: the outsized appeal of free food. It's not as if any conference attendees would have trouble affording a couple of bucks for a snack. In fact, many of us are on expense accounts. But throw out a tray of muffins or a case of soda and we're stuffing our pockets like a horde of street urchins.

Weirdest souvenir: The ACR daily paper encouraged attendees to purchase a "Rodman Commemorative Gout Print." Your guess is as good as mine.

Strangest wardrobe: It may have related to the high percentage of foreign attendees, but spotted at ACR were a mullet, a pink fringed suit, and a study author's top so sparkly it could have blinded a cameraman.

Marketing gone wildest: In a montage promoting MGMA 2009, screen faded from e=mc2 to DEN=mc2, to DENVER. Hunh?

Most mysterious session title: Indian Hedgehog and Parathyroid Hormone-related Protein Regulate Articular Chondrocyte Differentiation.

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posted by Stacey Butterfield at 8:00 AM   2 Comments

Visiting the dark side at MGMA

Learning about the business of medicine can be fun, even inspiring. I'm looking forward to writing up MGMA sessions on reducing no shows and improving the wait room experience for upcoming issues of ACP Internist.

But this afternoon, a couple of sessions wavered in the delicate balance between profit and clinical motives. First, a hospital exec who was trying to up his patient satisfaction scores explained how his organization told their docs to improve patient contact by thinking about "how you would do things differently if you valued the person in front of you." Implication being that the average patient previously had no value?

Then I went to a session on a topic that always riles our high-minded readers: medical spas and retail medicine. (I didn't mean to be there. The "Day in the Life of an EMR Physician" session was unexpectedly cancelled.) And it was painful.

The speaker (a lawyer) started off by talking about the impending primary care shortage. Which seems to me like an argument against spa medicine, since we might need those few docs who are left for real clinical care, but I suppose it's also a market opportunity. Anyway, apparently these spas are offering everything for which patients will open their wallets, from massage and Botox to hormone replacement therapy. Wait, isn't HRT a medical therapy that you should provide to patients based on the (substantial, hotly debated) evidence rather than the price they will pay? (I didn't get to ask.)

After a brief discussion of all those pesky regulations that medical boards and government regulators impose on the fortune-making possibilities of medicine, we moved on to retail clinics. The speaker predicted that more physicians will be getting offers to supervise in-store clinics that are staffed by NPs and PAs. The bad news is, legal constraints mean they might actually have to do work, like reviewing charts. "It's not just show up at WalMart every two weeks and pick up a paycheck," he said.

I know, physicians need to be paid, and medicine is still a capitalist enterprise (although after banking, who knows what's next). But after my foray into the biz of medicine, I'm ready to hop back over to clinical side of the wall.

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posted by Stacey Butterfield at 5:31 PM   0 Comments

The requisite motivational lecture

This morning at MGMA, expert/consultant Quint Studer gave the group some tips on how to improve performance of their medical groups. His top recommendation was to fire your bad employees.

A few less obvious tips:

• He suggests using pre-visit phone calls to reduce no-shows. The interesting twist--while you've got them on the phone, ask for credit card payment of the copay. Saves time during check-in and gives them more to lose by noshowing.
  
• Studer's designed a little brochure called a "patient visit guide" that is intended to improve compliance and satisfaction. Patients write down their chief complaint on it, then nurses fill in vital stats, and docs add follow-up (particularly medication) instructions. Patients then take it home, and have a clear idea of what happened during the visit. There's supposed to be an online version of the form on Studer's web site, but I haven't found it. Will do some more investigation.

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posted by Stacey Butterfield at 1:05 PM   2 Comments

What the managers are thinking

I (and the rest of the press pool) had lunch with MGMA president and CEO William F. Jessee, MD, today and he offered some thoughts on current events.

Already, the effects of the economic meltdown are starting to be felt among MGMA member practices, who are reporting recent decreases in patient volumes. There are also expectations that uninsured populations will go up along with the unemployment rate. In addition, practices are now holding off on big capital expenditures, Dr. Jessee said. That's bad news for the MGMA conference, for one, since you can't walk the exhibit hall without tripping on an EHR vendor. "I'm curious to see how our conference will look next year," said Dr. Jessee.

The MGMA is challenging the next president to concentrate some of his administration's health reform energy on payment reform. "Neither of the candidates is addressing the core issue," said Dr. Jessee. Key points that he would like to see addressed: universal coverage (the MGMA has not taken a stand on single vs. multiple payer); changing reimbursement to reward physicians for keeping patients healthy; aligning incentives so that physicians, hospitals and payers can work together instead of against each other; and reducing administrative waste.

Toward that last goal, the MGMA is starting a big push for standardized patient ID cards. Right now, they're doing research to show that insurance cards with magnetic stripes or bar codes that have basic patient and payer info encoded in them would save time and money for everyone involved. The next step is getting payers on board with the idea. A small step toward simplifying the administrative nightmare that is modern healthcare. Says Jessee, "We pitched this one because it's so simple even a legislator can understand it."

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posted by Stacey Butterfield at 5:37 PM   0 Comments

EHRs at 8 a.m.

I'm at the Medical Group Management Association's annual meeting this week, in not-so-sunny San Diego.

This morning, I started off by going to a lecture about the operations of the Certification Commission for Health Care Information Technolgy, the recognized certification body for electronic health records, which was founded by the Healthcare Information and Management Systems Society and HEY! DON'T FALL ASLEEP! I'M STILL TALKING HERE!

Anyway, I managed to stay awake for a few interesting facts. First, despite all the talk about how Stark exceptions will let hospitals give EHR systems to physicians, very few are actually doing that. Specifically, the MGMA rep said that he's never met anyone who got their EHR that way, and the CCHIT director suggested about 100 hospitals have actually done it. Biggest hurdle, according to the speakers: disputes over who controls the data in the records.

But, one entity that actually is encouraging EHR adoption: malpractice carriers. Both speakers said they've talked to liability insurers that are offering up to 5% off premiums if you have an EHR. (There's no proof yet that electronic records lower claims, but they do improve documentation.) Depending on the size of your premium, that discount might pay for a significant chunk of your EHR costs, the experts suggested.

And, a few of the mysteries of CCHIT certification were revealed. When you're looking at an EHR, the more recent the certification, the better, but don't rule out a system that's still 2008 certified in the spring of 2009, they said. The certification cycles run from August to August, so no one will have the current year's certification until the summer at the earliest. Also, certifications are good for two years, but vendors should state in their contracts that they will get renewal of their certifications when needed.

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posted by Stacey Butterfield at 12:28 PM   0 Comments

It's that time again

After the traditional summer slowdown, conference season is about to get underway, and that means it is once again time for...Ill-advised Session Titles. Here are a few treasures from the Medical Group Management Association, whose annual meeting I'll be blogging from Oct. 20-22.

"The Ring in the Rubble: Dig Through Change and Find Your Next Golden Opportunity" People, how many times do we have to tell you that metaphors are like fudge--a little bit is amazing, but a lot is unhealthy and nauseating?

"How to Get Your Front End to Meet Your Back End" What do you bet several attendees arrive with absolutely the wrong idea in mind? This is a business seminar!

"I Hate to Wait!" Fair enough, but I'd better not have to sit around while you fiddle with your PowerPoint.

and our nominee for Excessively-Wordy-But-Can't-Miss-Session-Title, "Our Physicians Make More Money, Go Home on Time and Provide Better Care".

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posted by Stacey Butterfield at 12:00 PM   0 Comments