Elephants in the Room

ACOs and other new acronyms have swamped the minds of physicians and healthcarebusiness people alike since the terms were coined. The still new healthcare reform law continues to worry many and challenge others to figure out ways to play the game and win. While we scurry around chasing the regs and the new words and government agencies, while politics keeps moving the ball and shaping the healthcare agenda, the most central issues in healthcare cost/quality debate are not even discussed. It’s as though policy makers and business is saying “Hey, if we keep throwing new regulations at them, maybe they’ll stop asking really tough questions we can’t answer.”

Back in the 80s, the state of Oregon enacted Medicaid reform that took the breath right out of the rest of the country. Remember? The idea that a state would not list ALL medical services to ALL Medicaid patients was considered to be cruel and impolitic at the time. And the national debate about (1) whether healthcare is a right of American citizens, and if so (2) what healthcare services are “in” and which are “out” has grown virtually silent.

Instead, it seems we have entered the area of political intransigence. It appears that getting and staying in political office requires as little change as possible. So, very little seems to be accomplished or even discussed.

So what are the “elephants in the room?” They are the issues of “how much” and “patient accountability.” Though it appears that the issue of whether we Americans are entitled to receive healthcare has been skirted, we are clearly missing any discussion on the issue of how much services. Oregon hit the issue head on, but nationally there appears to be no movement or even discussion of the issue. We don’t know who should get what. We just know we want to reduce the costs (ration).

Virtually every effort to reduce costs so far has involved the use of managed care organizations. The Florida Medicaid program pilot project that began in Broward County in 2006 has produced two clear results—reduced expenditures and huge criticism that managed care has reduced costs solely by reducing access and care itself. Managed care has become the “black hat” that politics won’t pick up. It’s ok for managed care to restrict access and care because it reduces costs, but it is politically impossible to directly address the issue of “how much.” We rely on managed care to do it for us, due to our political inability to tackle the issue, then blame the payers for their (wink wink) bad behavior. If managed care is profiting, it is only because they don’t mind profiting from our unwillingness to take responsibility for the issues they deal with on a daily basis—saying “no.”

The second elephant is the issue of patient accountability. There is none! What is the consequence of patient bad behavior? What consequence is there for refusal to exercise, quit smoking, etc.? None. We pay more. There isn’t a single provision in any federal law that punishes us for making expensive healthcare decisions or that rewards us for making cost saving healthcare decisions.

I liken it to having teenagers. Expectations with no consequences yields a predictable result of no change in behavior. Simple.

These are huge issues to tackle. So many different kinds of people, agendas and ways of seeing the issues. So, we don’t even try. Instead, we “hire” managed care to bear the burden of our failure to address and answer these issues. And we throw complex ideas like metrics and healthcare reform into the market, which only serves to distract us from addressing the root causes of our healthcare challenges.


CMS Seeks to Delay E-Reporting Requirement

The CMS has proposed an array of rule changes affecting physicians and their use of health information technology under various Medicare and Medicaid payment regimes, including delaying for at least a year a requirement for the direct, electronic reporting of physician quality data as part of the meaningful use requirements of the electronic health-record incentive payment program under the American Recovery and Reinvestment Act of 2009.

“One key change in the rule is a proposal to continue to allow physicians and other eligible professionals (collectively referred to as EPs under the program) to qualify as having met a portion of their meaningful-use requirements for clinical quality measures by submitting attestations to the CMS.”

The 621-page proposed rule, released by the CMS this month, but not scheduled for official publication in the Federal Register until Wednesday, is open for public comment through August 30.

Via Modern Healthcare  7-13-2011

What To Consider When Buying A Medical Practice

As physicians retire and the era of healthcare reform rocks physicians, opportunities to purchase practices will likely surge, and not just for entities that employ physicians, like hospitals.  The big issues generally break down like this:

  1. What to pay;
  2. How to structure it; and
  3. How to pay for it.

The Price

It depends on what you’re buying.  If all of the practice income is from personal services performed by the selling physician, the answer is generally “not a lot.”  The price typically consists of (1) the value of the fixed assets (e.g. equipment, furniture), and (2) maybe a little more in order to avoid the cost of starting up a new practice from scratch.  In the event, however, the practice also generates income from services that are not personally provided by the selling doctor, the price is increased to account for this “passive revenue.”  How much?  Maybe the amount of one year’s profit from that ancillary service.

Structure

Practice purchase take one of two forms:  (1) stock purchase, or (2) asset purchase.  Buyers that buy the stock of a medical practice are rare because the buyers get all the liabilities associated with the stock of the selling practice.  Most practice purchases are asset purchases, which makes it easier to say what you’re buying, what you’re not buying, which liabilities you want to assume (e.g. leases) and which ones you don’t want to assume.  Sellers often prefer stock purchases because the seller gets better tax treatment on the purchase price (capital gains instead of ordinary income) than sellers who sell just their assets.

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Federally Funded Electronic Health Recordkeeping: Friend or Foe?

The Federal HITECH Act will provide over $20 billion to promote health care provider use of electronic health records.  Starting this year, “meaningful” EHR users can earn $44,000 under Medicare and $64,000 under Medicaid over 5 years.  Those who enroll early will benefit the most, because nearly 70% of the payments come in the program’s first 2 years.  Physicians who have engaged in PQRI and electronic prescribing in the past few years have put another $6,000 to $8,000 in their pockets.

The Federal push for electronic health records isn’t going away.  Over $7 billion has been released to fund state capacity for exchanging health information across the health care system both within and across states.  The Florida Agency for Health Care Administration received nearly $21 million to develop this state’s health information infrastructure.  The intent is to assure a fully connected national health care IT system to provide all health care providers and their patients seamless access to a patient’s medical information.

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