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Private Practice Doctors

Private Practice Insights: The MICRA Showdown

November 20, 2013

By Stuart A. Bussey, M.D., J.D., UAPD President

As the showdown for the latest cycle of tort reform heads for the California legislature and the ballot box in 2014, it’s time to review the arguments of both sides.  More importantly, it’s time to offer some possible solutions to the problem.  Trial attorneys want to protect patients against “negligent” physicians, while we physicians counter that we are trying to protect patients from indirectly bearing the costs of malpractice premiums.

California’s 1975 MICRA law, spearheaded by UAPD and the CMA, set a cap of $250,000 for a patient’s “noneconomic” damages (pain and suffering).  That’s good for keeping doctor’s malpractice premiums at a reasonable level.  There is no ceiling for economic losses of the patient.  That’s good for the patient who has legitimately had his livelihood impaired by provider negligence.  MICRA has kept malpractice premiums in check for years, but now trial attorneys are asking to raise the cap on noneconomic damages to $1.2 million or more.  We strongly support maintaining the $250,000 cap on non-economic damages.
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Private Practice Insights: Rate Increase for Primary Care Services

October 30, 2013

The Federal Affordable Care Act (ACA) requires Medi-Cal to reimburse certain primary care services for eligible physicians at parity with Medicare rates for dates of service in 2013 and 2014. The purpose of this reimbursement rate increase is to acknowledge the importance of physicians in achieving quality outcomes and to increase access in preparation for Medi-Cal expansion in 2014.  CenCal Health has put together this helpful guide to get you started.
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Private Practice Insights: Pocket Cardiologist

August 1, 2013

By Stuart A. Bussey, M.D., J.D., UAPD President

We all know by now that a good EHR system can be used to reduce medical errors and improve patient outcomes in diabetes and other diseases.  The downside of technology is the reduction of human contact in the doctor-patient relationship.  Now comes the “pocket” cardiologist.

The device is an ECG monitor under review by the FDA.  A patient can now use a smartphone to record  a quality ECG with accurate rhythm, heart rate, and variability. Such a device has already successfully detected an ischemia induced rhythm change in a patient.  As in other areas of telemedicine the concern for doctors is too much data without adequate clinical correlation.

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Private Practice Insights: Better Records, Better Compensation

August 1, 2013

By Stuart A. Bussey, M.D., J.D., UAPD President

There is a delicate balance between documentation and insurance reimbursement. Insufficient records can mean rejected claims, while excessive and unsupported coding can invite an audit, EMR templates may tempt a provider to clone his/her reports and that would be a mistake. One size does not fit all. Notes should be as precise as possible. Most doctor’s notes are not complete enough to meet coding and billing requirements. An even greater cause of records audits is “medically unnecessary” treatment. In order to show that treatment is medically necessary the patient record should tell a story. The chief complaint is like the title of the story, while the history sets it up and the exam fills in the details. Your medical decision making is the end of the story. Besides the usual SOAP components of the record are contributory notes which can upgrade your reimbursements. Individual counseling, coordination of care and exact time spent with the patient can augment payment. Besides legibility your records should present a clear rationale for ordering diagnostic and ancillary services, cover past and present diagnoses, health risk factors and report on the patient’s response to treatment. CPT and ICD-9 codes must be supported by the record. A weekend coding workshop for you and/or your staff may pay big dividends for you.

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Deane Hillsman Obituary

July 11, 2013

For more than a quarter of a century, Deane Hillsman was the conscience of the UAPD.  Whenever a physician whistleblower got into trouble for telling the truth about an important medical issue, Dr. Hillsman would stand up to support the doctor regardless of how  powerful the adversary may be.

Early in his career as a private practice pulmonologist in Sacramento, Dr. Hillsman became a whistleblower.  He paid a heavy price for supporting his patients.   His hospital retaliated against his medical staff privileges.  It took years for Dr. Hillsman’s legal actions to wind their way through the courts, but he won a total victory.   His own case made him realize how difficult it was for an individual doctor to fight the system.  He became an early supporter of the Union of American Physicians and Dentists.  Read more …

Private Practice Insights: Geezers

July 1, 2013

By Stuart A. Bussey, M.D., J.D., UAPD President

As an aviation medical examiner I have had to give first class airline pilots the bad news that they are not medically eligible for their pilot license after they reach the age of 65.  Fortunately,  this mandatory retirement age does not apply to us physicians.  But there is an increasing call to monitor older doctors in order to ensure patient safety.  Sensory , motor and cognitive skills are prone to decrease in older physicians.  In the general population between 3 and 11% of seniors develop dementia and the early signs are easy to miss.  About 5% of hospitals have age based medical policies.  Some are recommending that hospitals require annual renewal of privileges for those over 70 as a “fitness for duty” evaluation.  And we are all too familiar with the Medical Board’s predilection for investigating older doctors.

As the recession lingers on an increasing number (20%) of older licensed doctors in the US continues to practice medicine.  This issue bears increasing importance to the general public.  Many Specialty Boards are responding by requiring more frequent recertification exams and continuing practice improvement modules.  These exams and modules, however, do not apply to those “grandfathered” physicians who earned their initial boards before 1990.  About a half of US hospitals require such recertification exams.

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Private Practice Insights: Covered California

June 1, 2013

By Stuart A. Bussey, M.D., J.D., UAPD President

With summer on the horizon the heat will be increasing on medical providers. Last week Peter Lee, director of the new Covered California health insurance exchange, announced that 13 health plans have been selected to participate. These plans will offer coverage to millions of previously uninsured Californians. The selection of these plans is subject to a rate review by the state. The rates submitted by the plans averaged only $320/month for an individual—substantially lower than the rates for most small employer plans. The “winning” organizations, including new entrants as well as giants like Kaiser, built their bids around the expectation of high enrollment. Supposedly, even rural areas in California will have access to at least one plan in the exchange. The competition for patients in the current ACA environment is causing a rate war to attract patients. Patient loyalty to providers will be tested. Healthpocket, a website that rates and compares health plans, asked 713 consumers if they would be willing to change physicians if it meant saving money on premiums. Though 40% said they would not change doctors, 34% thought that saving between 500-1000 dollars annually would justify such a switch.

Private Practice Insights: Anti-Fraud Campaigns

April 1, 2013

By Stuart A. Bussey, M.D., J.D., UAPD President

Fraud costs the US healthcare system about $65 billion last year from Medicare alone.  The ACA provides the Center for Medicare Services (CMS) with funding to adopt new tools to identify fraud and abuse.  Last year the health care fraud and abuse control program recovered over $4 billion. There will undoubtedly be an increase in audits of our practices.  MAC program safety contractors and OIG investigators will be scrutinizing our claims.

But not to worry.  The threat of an audit is much greater for hospitals and “large” physician practices.  Improper coding for the level of service is the most common practice mistake, especially when an ancillary provider is involved.  For smaller practices like my own the challenge is to reduce mistakes and patterns of errors that could attract the attention of auditors. It is important to put systems in place to prevent fraud.  First, establish a culture of compliance. Make it clear that doctors associated with the practice care about following the rules.  Second, educate and train your staff.   Take advantage of free information from government sources.  Do the right thing when problems arise.  Under ACA the failure to refund an overpayment within 60 days is a potential false claims case.  Build a compliance plan.  Physicians can avoid problems by taking time to conduct audits on their own records.  Use a preventative philosophy and you’ll stay out of trouble.

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Private Practice Insights: Quality Pay

March 1, 2013

By Stuart A. Bussey, M.D., J.D., UAPD President

Whether you are a UAPD member in county employment or private practice you are affected by Pay for Performance.   The Hay Group recently calculated that roughly two thirds of health care organizations incorporated quality measures into physicians’ incentive programs.  If you are in such programs you need to ask yourself and your organization some important questions.  First, what exactly is being measured? Will the assessment be based on claims data or on medical record audits?  On target metrics or merely improvement?  Is the target reasonable? For instance, in my IPA the colorectal cancer screening compliance target is over 80%.  That means at least ¾ of your patients must get either endoscopy or submit occult blood smears during the year measured.  In my experience that is overly ambitious.  The next critical question is how to meet these quality measures.  Ask your organization to provide you with baseline data.  If they expect 80% compliance from you and their average is currently 25% that is not a reasonable expectation.  You should create a system in your practice-on either charts or EHR– to remind you or your staff to ask your patients to come in for an exam or test.  With many patients this can be a daunting task.  Collecting and collating all these tests and data may require additional staff or even a case manager for large practices.  Performing well on the P4P metrics is a team sport and employee reimbursement should be based on how well you all do.  The trend for P4P is definitely upward.  Forbes Insight predicts that between ¼ and ½ of physician revenue will be based on incentive within five years.

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Private Practice Insights: Working More, Making Less

February 1, 2013

By Stuart A. Bussey, M.D., J.D., UAPD President

Here are some statistics from Medical Economics that confirm what we already know—doctors are working long hours to see more patients and taking home less money.  For instance, in the 2012 Medical Economics survey, internists worked a median of 51 hours per week, unchanged since 2008.  Family physicians had a median of 50 hours, also without a significant change.  Both groups saw about 98 patients per week on average.  There were some gender and age differences.  Men worked about 51 hours a week while women averaged 47 hours a week.  Docs over age 65 averaged only 77 patients a week while younger doctors below 35 averaged 83 patients a week.

Some possible explanations for the increase in hours and patients: doctors are paying better attention to their schedule due to the efficiencies of EHR, adding more convenient hours, filling time gaps, or adding hospital and nursing home visits.  Demanding that patients come in instead of utilizing phone or email may be another explanation.

 

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