Diabetes Practice Options, July 2011

OPTIONSDIABETES PRACTICE

™

Improving Patient Care Through Increased Practice Efficiency

Visit www.DiabetesOptions.net to view our digital edition and for more practice options information.

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The Physicians' Foundation

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JULY 2011

EDITORIAL

3 | DIABETES STRATEGYPatients’ Self-Care May Be Improved by Addressing Competing Demands on Time

6 | CAPITAL IDEASRegularly Review Financial Advisers toKeep Abreast of Changes to Financial Systems

8 | TECHNOLOGYPatient Check-In Devices Streamline Front Office Function, Improve Payment Capture

11 | COMMUICATIONHow Social Media Will Affect Medical Practices and the Health Care System

13 | HEALTH CARE REFORMProposed CMS Rules Seek to Lower Care Costs Through Increased Transparency

14 | PRACTICE MANAGEMENT NEWSAHRQ Report Finds Disparities in Care Between States

I’m writing this editorial while on vacation in Paris. At lunch earlier this week, I spokewith a Canadian couple from Toronto, an anesthesiologist and a dentist. The wifeextolled the virtues of the French system. Earlier this year while staying in the French

countryside her teenage grandson woke in the middle of the night with a fever and asevere sore throat. She called SOS Medicin, a physician house-call service, and within anhour her grandson was visited by a physician. The physician charged 55€ (about $75) andapologized for writing an expensive prescription that cost 10€.

As a pediatrician and an advocate for healthy nutrition for our youth, I was astoundedat the apparent lack of a significant (by current U.S. standards) obesity problem in theFrench children that we’ve seen. One afternoon, as my wife and I were sitting on a parkbench across from a public school, hundreds of French teens poured out onto the street

Continued on page 2

CONTRIBUTORS

Jason O’Dell, CWM

Christopher Jarvis, MBA

France Provides a Good Example of Access to Primary and Preventive CareBy Michael Bihari, MD, contributing editor

Page 3

IN THIS ISSUE

Neil Baum, MDUrologistNew Orleans

Daniel BeckhamPresidentThe Beckham Co.Physician and Hospital ConsultantsWhitefish Bay, Wis.

Harold B. Kaiser, MDAllergy & Asthma Specialists, PAMinneapolis

Nathan KaufmanPresidentThe Kaufman GroupDivision of Superior Consultant Co. Inc.Physician and Hospital ConsultantsSan Diego

Peter R. Kongstvedt, MDP.R. Kongstvedt, LLCMcLean, Va.

John W. McDanielPresident and CEO Peak Performance Physicians, LLCNew Orleans

Lee Newcomer, MD, MHASenior Vice President, Oncology UnitedHealthcareMinneapolis

James M. Schibanoff, MDEditor in chiefMilliman Care GuidelinesMilliman USASan Diego

Jacque Sokolov, MDChairmanSokolov, Sokolov, BurgessScottsdale, Ariz.

This newsletter is published by Premier Healthcare Resource, Inc., Morristown, N.J.

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EditorRev DiCerto845/[email protected]

Art DirectorMeridith Feldman

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EDITORIAL

EDITIORIAL BOARD

with never a high BMI in sight. We wereastounded that neither of us was able to spotan overweight kid.

In our local high school in New Englandmore than 25% of the kids are overweight orobese. According to comparative data fromthe World Health Organization, the per-centage of the French population with abody mass index (BMI) of more than 30 is16.9%, while for the United States the figureis 34.1%. The French live longer (82 yearsversus 78 years on average) and spend lessthan Americans on health care (11% of GDPversus 15.7% of GDP annually).

Type 2 diabetes data are also telling, since8.3% of the U.S. population has been diag-nosed with diabetes while for France thenumber is 4.6%. In the United States thenumber may actually be higher, becausemany cases of diabetes are not diagnosed. InFrance, because of vigorous screening andawareness, most people with diabetes havebeen identified.

The French love American fast food;McCafes are popping up all over Paris andother French cities. In fact, the branch onthe Champs Elysees is the biggest moneymaker in the world for the franchise.However, the French government has elimi-nated junk food from schools and spendsmillions of Euros every year to educateyouth and their parents about nutrition andfitness.

C’est la Vie!�

STAFF

Continued from page 1

2 Practice Options/July 2011

More information is available atwww.DiabetesOptions.net

Michael Bihari, MD

Diabetes patients are required todevote considerable effort toself-managing their disease.

Activities such as glucose monitoring,attention to dietary choices, physicalactivity, and implementation of com-plicated medication regimens requiresignificant time and energy. A studypublished in the May 2011 issue ofDiabetes Care quantifies how compet-ing demands for time, including caregiving and employment responsibili-ties, can affect a patient’s self-carebehaviors and outcomes of care.

“Our research findings suggest that toimprove clinical outcomes, physiciansmust understand the demands on eachpatient’s time and try to help that patientdevelop strategies to build self-manage-ment activities into their daily lives,” saysWilliam H. Herman, MD, MPH, anendocrinologist and professor in theDepartment of Internal Medicine at theUniversity of Michigan in Ann Arbor,one of the study’s co-authors. TheUniversity of Michigan study consistedof an analysis of data from TranslatingResearch Into Action for Diabetes(TRIAD), a multicenter prospectiveobservational study of diabetes care thatinvolves approximately 12,000 diabetespatients enrolled in managed care plansacross the United States.

Patient ChallengesDiabetes patients face a number ofchallenges due to the time-consumingnature of self-care requirements, notesLaura McEwen, PhD, MPH, a seniorepidemiologist at the University ofMichigan and also a study co-author.“The self-care required of diabetespatients involves many different per-sonal health behaviors, includingdietary modification, regular physicalactivity, foot care, self-testing of bloodglucose levels, and medication man-agement and administration,” she says.“Therefore, physicians who treat dia-betes patients should expect that thetime involved for self-care will be achallenge for many of their patients.”

Previous research has highlightedthat self-care can be quite time-con-suming for diabetes patients. Forexample, a cross-sectional analysis of1,482 diabetes patients enrolled inthree managed care plans published inthe July/August 2005 issue of theJournal of the American Board of FamilyPractice found that diabetes patientsspend approximately one hour per dayon self-care. Furthermore, many dia-betes patients did not perform selectedelements of self-care. Of the patientsexamined, 37.9% reported not com-pleting foot care, 37.7% did not exer-

cise, and 54.4% spent no time on foodshopping or preparation.

A qualitative study published in theJanuary 2005 issue of the Journal ofFamily Practice that involved interviewswith certified diabetes educatorsreported that experienced patientsusing oral agents to manage type 2 dia-betes require more than two hours perday to perform all recommended self-care activities. Certain groups ofpatients, such as elderly patients,patients with newly diagnosed disease,and patients with physical limitations,devote even more time to managingtheir condition, the study found. It alsofound that diet and exercise require-ments were the most time-consumingself-care tasks for diabetes patients.

“We wanted to see if the major com-peting demands on patients’ time—employment and caring for a child ordisabled relative—had a measurableimpact on patients’ ability to completeprocesses of care, which in turn couldaffect their clinical outcomes,” saysMcEwen. “Previous studies on compet-ing demands for time and self-careprocesses in diabetes patients havefocused largely on African-Americanwomen living in the southern UnitedStates, studying how care-givingresponsibilities affected the time thesewomen had allotted for self-care. Wecould not identify any studies that eval-uated the impact of competingdemands for time on both men andwomen, the impact of employment onself-care, or the impact of competingdemands for time on diabetes diseaseoutcomes. Overall, our study is uniquein that it involved a more diverse popu-lation in terms of gender, race, geogra-phy, education, and socioeconomic sta-tus, as well as a broader definition ofthe activities that constitute competingdemands.”

Reduced Self-CareFor both men and women, theresearchers found that employmentresponsibilities with or without care-giver responsibilities were associatedwith lower rates of diabetes self-care

Continued on page 4

Practice Options/July 2011 3

DIABETES STRATEGY

Patients’ Self-Care May Be Improved byAddressing Competing Demands on Time

DIABETES STRATEGY

behaviors, poorer compliance withprocesses of care, and higher blood glu-cose levels.

The analysis identified a number ofexamples of how competing demandsfor time affect self-care activities. Forexample, among female diabetespatients, 53% who had both care-givingand employment responsibilities weretaking aspirin, compared to 63% ofpatients without such responsibilities.Similarly, 59% of menwith both types ofresponsibilities hadreceived influenzaimmunization, com-pared to 71% of menwith neither care-givingnor employmentresponsibilities. Thetrends were similar forboth genders for nearlyall processes of care,although not all resultswere statistically significant.

When the researchers compared therelative impact of employment respon-sibilities versus care-giving responsibil-ities on processes of care, they foundthat employment responsibilities had agreater negative impact. Among men,those with employment responsibilitiesonly had lower rates of foot care (53%

versus 58% of men with care-givingresponsibilities only), as well as lowerrates of self-monitoring of blood glu-cose in oral medication users (33% ver-sus 38%). Among women, employmentresponsibilities only were associatedwith lower rates of glycemic controlbeing assessed (82% versus 86% forwomen with care-giving responsibili-ties only), influenza administration(66% versus 72%), and fewer processesof care.

“The time demands associated withemployment outside of the home arelikely to be less flexible than care-givingduties, making it more difficult for dia-betes patients to accommodate theirschedules to their self-care needs,” saidHerman. “For example, patients whohave employment responsibilities mayfind it more difficult to schedule doctor

or nutritionist office appointments out-side of business hours.”

Poorer OutcomesThe presence of competing demandsfor time was also associated with poor-er intermediate outcomes. For exam-ple, male diabetes patients with nocompeting demands for time had amean HbA1C level of 7.81, comparedto 8.16 in men with care-giving respon-sibilities only, 7.98 in men with

employment responsi-bilities only, and 8.32for those with bothtypes of responsibili-ties. Women with care-giving responsibilitieshad a higher meanHbA1C (8.17) thanwomen with no com-peting demands fortime, who had a meanHbA1C level of 7.86.

HbA1C was also higher for womenwith both types of responsibilities com-pared with women with no competingdemands for time, although this differ-ence was not statistically significant.

“Interestingly, competing demandsfor time had more of an impact onblood glucose levels than on bloodpressure or cholesterol control,” says



Astudy published in the May 2011 issue of Diabetes Carethat quantifies how competing demands for time canaffect a patient’s self-care behaviors and outcomes of care

consisted of an analysis of data from Translating Research IntoAction for Diabetes (TRIAD). TRIAD is a multicenter prospectiveobservational study of diabetes care that involves approximately12,000 patients with diabetes enrolled in managed care plansacross the United States. It is a ten-year project funded by theCenters for Disease Control and Prevention (CDC) and theNational Institute of Diabetes and Digestive and Kidney Diseases(NIDDK).

“The goal of TRIAD is to investigate the impact of health plan,provider group, physician, and patient factors on processes andoutcomes of care,” says Laura McEwen, PhD, MPH, a senior epidemiologist at the University of Michigan, a co-author of

the Diabetes Care study. McEwen notes that the Universityof Michigan is one of six TRIAD study sites. “We follow patients

over time using self-administered questionnaires and medicalrecord review. For this particular study, we included data from diabetes patients who completed the baseline and 18-month follow-up interviews, which limited our study populationto 5,478 respondents.”

Using statistical techniques, the researchers evaluated theassociation between competing demands for time, sevenprocesses of care (aspirin use, dilated eye examination, footexamination, glycemic control assessment, influenza administra-tion, LDL cholesterol assessment, and proteinuria assessment)and three intermediate diabetes care outcomes (HbA1C level,systolic blood pressure, and LDL cholesterol).

—DJN

UNIVERSITY OF MICHIGAN DIABETES SELF-CARE STUDY SURVEYS TRIAD DATA

“Physicians have limited time… and a limited ability to influence those aspects of their patients’ lives that affect both motivation and ability to comply with treatment recommendations.”

—William H. Herman, MD, MPH, University of Michigan, Ann Arbor


One of the things we have learned from TRIAD [TranslatingResearch Into Action for Diabetes] analyses is that healthsystem organization and structure can have a major

impact on processes and outcomes of care for diabetes patients,”says William H. Herman, MD, MPH, a professor in the Departmentof Internal Medicine at the University of Michigan in Ann Arbor,co-author of a study on the effects of competing time constraintson the self-care regimens of diabetes patients. The study, whichwas published in the May 2011 issue of Diabetes Care, analyzeddata from the TRIAD study, in which the University of Michigan isa participant. “Holding early morning, evening and weekend

office hours in order to accommodate patients who work fromnine to five can have a meaningful impact on diabetes care qual-ity,” Herman says.

“Physicians could potentially offer more convenient officehours or possibly communicate by phone or e-mail to provide amore expedient mode of communication with their patients whohave busy lives,” adds study co-author Laura McEwen, PhD, MPH,a senior epidemiologist at the University of Michigan. “Improvingaccess to care via greater flexibility could potentially improvepatient adherence to the recommended self-care behaviors thatcould, in turn, lead to improved diabetes outcomes.” —DJN

FLEXIBLE PRACTICE STRUCTURE COULD AIDDIABETES PATIENTS IN MAINTAINING SELF-CARE

McEwen, speculating that these find-ings reflect the fact that controllingblood glucose is more time-consum-ing. “Blood pressure and cholesterolcan often be adequately controlled withonce-daily medications, whereas bloodsugar control is more challenging,requiring frequent self-monitoring ofblood sugar levels and more frequentmedication administration as well ascareful attention to diet and physicalactivity.”

Implications for Physicians “It is critical for physicians to be awarethat patients do have competingdemands for their time, requiring themto juggle many responsibilities—including self-care activities—everyday,” notes Herman. “Whenever possi-ble, physicians should ask their patientsabout their competing time demandsand how these demands may affecttheir self-care behaviors.”

“I believe physicians are well awarethat competing demands for time canaffect patient outcomes,” observesMcEwen. “However, they may not beaware of the specific demands eachindividual patient faces. Physicians canask patients to identify the particularconcerns and pressures in their livesand the scheduling limitations thatmight constitute obstacles to compli-ance with self-care recommendations.”

Once these competing demands areidentified, physicians can talk to theirpatients about how to manage thedemands of diabetes self-care while stillmeeting daily responsibilities.“Physicians can also identify medica-tion-related strategies that can help,”says Herman. “For example, physiciansmay be able to modify drug regimensin ways that will help improve conve-nience and, therefore, adherence.”

In general, patient-level variables areextremely important with respect toprocesses and outcomes of care, notesHerman. “Research has shown thatyounger diabetes patients seem to havemore difficulty with compliance thanolder patients,” he says. “Similarly,poorer and less educated patients seemto have poorer processes and outcomesof care. To improve care quality, physi-cians must recognize the importance ofpatient characteristics like income,education, and competing demands fortime, and try to tailor care recommen-dations to suit individual circum-stances. In addition, systems of careshould be designed so that they canbetter support the needs of both physi-cians and patients.”

In a practical sense, physicians’ con-trol over patient-level variables is limit-ed. “Physicians cannot always influencesystems of care when working in amanaged care environment or when

dealing with health plans,” acknowl-edges Herman. “Physicians have limit-ed time to see each patient, and a limit-ed ability to influence those aspects oftheir patients’ lives that affect bothmotivation and ability to comply withtreatment recommendations. Yet theirapproach to working with an individ-ual patient is something that physicianscan control—so physicians can at leastacknowledge and discuss the issuestheir patients face during office visits.”

As an example,” Herman continues,“rather than telling a patient, ‘You mustmonitor your blood sugar four times aday and administer an insulin injectionfour times a day,’ the physician can askif the patient is employed and will facechallenges in adhering to that type ofregimen. A discussion may reveal thatwhile the patient may not be able tomonitor blood glucose at lunchtimeduring the workdays, more frequentmonitoring is possible on the week-ends. Then the physician can makeadjustments in treatment based on thatinformation. If limitations are present-ed by the patient’s lifestyle, the physi-cian and patient can discuss and identi-fy reasonable accommodations, mak-ing it more likely that the patient will beable to successfully manage his or hercondition over time.”�—Reported and written by Deborah J.Neveleff, in North Potomac, Md.

“


CAPITAL IDEASRegularly Review Financial Advisers toKeep Abreast of Changes to Financial SystemsBy Christopher Jarvis, MBA, and Jason O’Dell, CWM

The most common mistake seenby financial advisers who workwith physicians is in doctors’

choice of specialists. The successfuldelivery of health care is based onpatients’ need for physicians to referthem within and between specialtiesand subspecialties when unique chal-lenges arise. But when it comes to thenavigation of their own financialhealth, doctors do not apply the samelogic or expect the same level of sophis-tication from their advisers. As a result,doctors routinely receive and followadvice that is designed for the masses.

If a primary care doctor decided todiagnose and treat all surgical patients,it would be a case of malpractice. Yetthis is how doctors are treating theirfinancial planning when they don’t reg-ularly review, interview, and replacemembers of their advisory team astheir financial situation and needschange from residency to mature prac-tice to retirement. Even if your finan-cial goals do not change, tax laws andthe health care delivery system arechanging around you every month.Without a team working with you tohelp you address those changes, you arebound to become less efficient.

Reviewing AdvisersAs a quick test to see if you need to takea look at who is on your team, ask your-self the following questions:• Does your CPA regularly explain tax

law changes and offer suggestions tosave you money on taxes?

• Has your attorney explained the 2010estate tax changes and suggestedstrategies to transfer millions to yourheirs without losing control of thosefunds during your lifetime?

• Has your estate planner discussedwith you multigenerational planning

that will protect your heirs fromspending too much or losing inheri-tances to lawsuits or divorce?

• Have your tax and investment advis-ers explained tax diversification as a hedge against future tax rateincreases?

• Are you one of the smaller clients ofyour advisers, and do they specializein working with doctors on theirunique challenges?

• Have your advisers discussed yourlong-term view of the U.S. economyand explained investment strategiesthat provide hedges against a deval-ued dollar, increased inflation andinterest rates, commercial real estatecollapses, increased tax rates, andincreased costs of commodities suchas oil?

• Did your insurance expert explainhow you could receive up to $50,000per month of disability insurance, apartial deduction on your life insur-ance premiums, federal governmentsubsidies for your long-term care pre-

miums, and the tax benefits of insur-ance company ownership?

• Do your advisers communicate withone another to discuss your situation,bring in additional experts, and regu-larly make valuable suggestions toyou?If you answered “no” to any of these

questions, you are not taking advantageof existing opportunities and you aresettling for inadequate financial healthcare. Fortunately, there are tools doc-tors can use to help circumvent suchmistakes and avoid the unnecessarycosts that come with poor planning.

Life InsuranceHas your financial planner or insur-ance agent explained to you the twodifferent, equally acceptable, ways topurchase life insurance? Do you under-stand how “max funding” and “mini-mum funding” options work and whyalmost everything in the middle is anoverpayment of commission and a

Christopher Jarvis, MBA (left), has over 15 years of financial consult-ing experience. Jason O’Dell, CWM (right), is a financial consultant, lecturer, and the author of four books for physicians. He is a principal of the financial consulting firm O’Dell Jarvis Mandell LLC (www.ojmgroup.com), of which Jarvis is a member.


waste of your money? Do you under-stand how funds in insurance policiesmay or may not be protected even ifyou had to file bankruptcy? Are youaware that you could get a partial nettax deduction for your life insurancepremiums or buy life insurance withyour retirement plan (pre-tax) dollarsand leave almost all of the death bene-fit to your spouse tax-free? Did youknow you could buy life insurance,leave the death benefit to your heirs,and still have access to the cash valuewhile you are alive?

If you answered “no” toany of these questions, youeither hastily purchased yourinsurance or the agent hastilysold it to you. Cash value lifeinsurance can be a valuabletool for asset protection, taxmanagement, wealth accu-mulation, and estate plan-ning. But it must be usedproperly. Unfortunately, to use it prop-erly, the adviser needs to know a lotabout your situation, must take a greatdeal of time explaining the countlessoptions, and must coordinate theinsurance purchase with the otheradvisers on the team to maximize thebenefit you receive. The insurance pur-chases of most doctors are either poor-ly designed so cash values are not accu-mulating as well as they could with abetter design, owned improperly so

that funds will be left in the estate, orowned in irrevocable trusts where cashvalues are not available in the eventthey are needed.

Take time to get a better under-standing of how life insurance maywork for you. Don’t assume that youdid everything right because youragent told you that you did. Most poli-cies that advisers who work with physi-cians see as part of their comprehensiveinsurance reviews for new clients areinefficiently structured for the doctorsand their families. Not surprisingly, the

policies are almost always structured togenerate high commissions and are sel-dom structured to meet the goals ofmaximum tax-efficient accumulationor minimum cost of income replace-ment or estate liquidity, which are theonly two acceptable ways to purchaselife insurance as part of a well struc-tured, comprehensive financial plan.

Find Appropriate AdvisersIn medicine, doctors in each specialty

have a certain set of health concernsthey are uniquely trained for and dedi-cated to address for their patients.What many high-income Americansfail to realize is that their financial, legaland tax concerns are not well managedby generalists. Doctors need to build anadvisory team of subspecialists whonot only work with high-income, high-liability and high-tax rate clients butwho also understand the unique chal-lenges of working within the con-straints of a more complicated healthcare system that includes the Stark

laws, the Health InsurancePortability and AccountabilityAct (HIPAA), insurance fraudrisk, reduced Medicare reim-bursements, and other factors.

With the right team of sub-specialists, you can protectyour assets from lawsuits,taxes, and divorce while main-taining control of and access to

funds and successfully transferring$10-$15 million of today’s value tofuture generations. If you aren’t confi-dent that these goals are being met byyour advisers who have worked togeth-er to adjust your plan since the tax lawchanges in December 2010 or wouldlike a second opinion (review) of whatyou do have, please seek out the adviceof financial advisers who may be able tohelp you get to a place that you want tobe. �

Even if your financial goals do notchange, tax laws and the health caredelivery system are changing around

you every month.

Under the new tax laws, which may or may not last beyond2012, tools exist for doctors to easily leave $10-$15 milliontax free to their children and grandchildren. Doctors can do

this in a way that allows them to retain control of and access tothe funds while alive and leave the funds in a way that protectsthe recipients from losing their drive to be productive, losing theinheritance to a divorce or lawsuit, or having to do estate planningfor their children.

Unfortunately, this strategy requires customized planning, anddoctors often get “off the rack” solutions that don’t work. Over

90% of American families will never earn more than $150,000 peryear, be in the highest marginal tax bracket, or be worth more than$2,000,000. Accountants, financial advisers, insurance agents andestate planning attorneys do not spend the majority of their timedealing with people who have the relatively unique challengesdoctors do.

Download and read the 2010 tax law change summary and arti-cle at www.docworthy.com/2010estatetaxchange. Users will needto create a password. Then contact your estate planning attorneyto discuss the options that exist under the new law. —CJ, JO

CONSULT AN ADVISER BEFORE $10 MILLIONESTATE PLANNING OPPORTUNITY VANISHES

Busy physicians are constantlyseeking ways to improve theirpractices’ efficiency and improve

patients’ experience during office visits.In their efforts to streamline office pro-cedures and reduce staffing levels ordecrease staff overtime hours, medicalpractices in recent years have adoptednumerous solutions, including elec-tronic medical record (EMR) systems,patient engagement solutions, practicemanagement software, and a variety ofother technologies.

Just as daily administrative burdenscan place a significant financial strainon a medical practice by limiting thenumber of patients who can be seen,the need to collect co-pays and patientbalances can result in excessiveamounts of accounts receivable whenpatients unused to being asked to pay atthe point of service are unwilling orunable to pay, or, as is more commonlythe case, when front desk staff who arenot trained to request payment fail toask for it. Further potential for failingto capture payment is created whenoffice staff check patients’ insuranceeligibility, often using out-of-dateinformation provided by patients dur-ing previous visits. Uncollected patientbalances and co-payments are cited bymany physicians as a leading source oflost practice revenue.

Verifying EligibilityA group of devices that address theseconcerns among providers are referredto as patient check-in systems.Available from a number of manufac-turers, with a range of functions andfeatures, check-in systems seek tostreamline the patient check-inprocess. Many systems can aid in veri-fying patients’ insurance eligibility andcollecting co-pays and outstanding bal-ances. Some include other advanced

capabilities, such as the ability to collectpatients’ demographic data and offertargeted messaging related to theirhealth status and conditions.

“The device does real-time eligibilityand benefits [E&B] checks with theinsurance companies, which we werenever able before to do in real time,”says Shari Crooker, RN, practiceadministrator for Gwinnett CenterMedical Associates, an internal medi-cine practice in Lawrenceville, Ga., thathas been using the Phreesia check-insystem since June of 2009. “By the timethe patient gets to the company screens,it has already integrated his or herupdated co-payment information. Ithas already let us know whether thepatient is eligible or not, or if there issome missing information that eitherthe patient or someone from our prac-tice had entered erroneously, so we cancorrect it.”

Payment CaptureIn addition to E&B checks, the check-in system also asks patients to pay out-standing balances and co-payments atthe point of service. A “dumb termi-nal,” the PhreesiaPad has no hard driveor other means of storing any type of

patients’ financial or clinical informa-tion, and includes a scanner for readingcredit and debit cards. Having a devicethat automatically asks patients for alloutstanding charges has dramaticallyimproved Gwinnett’s rate of paymentcapture, Crooker says.

“Before, if the patient didn’t have themoney, or just didn’t bring their card,and the front office was busy, theyignored the co-payment,” says Crooker.“The staff would let the patient be seenby the doctor, the patient would sneakout, and we wouldn’t get his or her co-pay. We were rarely collecting balancesbecause the front office people didn’tknow when the patients had a balanceand didn’t bother to look, or wereafraid to ask the patient for the moneyup front. At the end of the check-ininterview, the pad pops up a screen ask-ing the patient to pay their co-pay now.They swipe their credit card on the padand pay on the spot. I recently lookedback at my time of service payments,which are co-pay balances, things peo-ple pay in the office. It was significant-ly increased.”

“The Phreesia system does some-thing that people often fail to do: wealways ask for payment,” says Mark


TECHNOLOGYPatient Check-In Devices Streamline Front Office Function,Improve Payment Capture

Shari Crooker, RN Mark O’Leary, MBA


O’Leary, MBA, the chief marketingofficer of New York, N.Y.-basedPhreesia, manufacturer of thePhreesiaPad. “If a patient has a finan-cial responsibility, then we ask for thatpayment.”

“We have started to capture the datafor the last 11 monthsnow, and we’re captur-ing nearly 95% of ouroutstanding balances,”Crooker says. “We’recapturing 100% of ourco-pays. SinceSeptember [of 2010],we are capturing$10,000 more a month by using thePhreesiaPad at the time of service.”

Collecting DataThe PhreesiaPad, which is able to inte-grate with numerous popular EMRplatforms, also collects patients’ clinicaland demographic data during thecheck-in interview. “It’s a rather lengthyinterview,” says Crooker. “It takes about12 minutes for the patient to completeon average, but it gets all the patients’demographic information. Then, thenext time they come back in, it is sim-ply an editing process.

“We actually developed three inter-views,” she says. “We have the longinterview for new patients, in whichthey fill out their insurance informa-tion, their address, their allergies, whatmeds they take, and why they are here,as well as a past medical history. In the

short interviews and the co-pay inter-views they don’t go through all that.That information is already there. Allthe patient needs to do is review it andedit it, if necessary. If their insurancechanges, they simply hit that ‘edit’ but-ton; they don’t have to go through theentire interview again.”

The system enables individual physi-cians to customize their interview tocapture different sorts of patient data.Each practice can decide how thesedata will be stored. The system isdesigned to automatically interfacewith numerous EMR systems.

Gwinnett uses an EMR fromeClinicalWorks. “Phreesia originallybuilt me an interface that used to printout the patients’ interviews, which wehad to scan in and add to the electron-ic documents,” says Crooker. “Thenthey built me a PDF interface. I have

one person doing intakes for acouple of minutes a day. Shefinds the patient’s name, andgoes into the EMR; the form isthere, so we no longer have toscan. Phreesia has also builtme an interface for the bal-ances on the co-pays. I hit twobuttons, I hit a comma sepa-

rated values [CSV] file, and it calculatesfrom the EMR into Phreesia for a quickcheck-in.

“Phreesia flags a patient’s record if itnotices that their information haschanged since their previous inter-views,” Crooker continues. “There’s alittle red star. My front office knows tolook for these little red stars and makesure we have the patient’s data enteredcorrectly.”

Based on the demographic and clini-cal information patients enter duringtheir interviews, Phreesia can be pro-grammed to offer targeted messaging.

Medical practices seeking to streamline the patient check-in process, improve their rates of payment capture forpatient balances and co-payments, and speed up eligibil-

ity and billing (E&B) functions in recent years have increasinglyturned to electronic patient check-in systems. While internal med-icine practice Gwinnett Center Medical Associates ofLawrenceville, Ga., along with over 10,000 other physicians in theUnited States, has found the PhreesiaPad from New York, N.Y.-based Phreesia a useful addition to its front office, a number ofother companies produce products designed to fulfill similar func-tions. These other check-in devices feature a range of overlappingfunctions, with varying degrees of clinical utility and patientengagement, to suit the needs of various types of medical prac-tices. Three prominent check-in devices are described below.

eClinicalWorks: Practice management software available fromelectronic medical record (EMR) manufacturer eClinicalWorks has

the capability to perform E&B checks, enable patients to scheduleappointments, collect demographic data, perform reporting, andmanage medical billing. According to the company’s Web site(www.eclinicalworks.com), the system does not yet have thecapability to process payments.

NCR MediKiosk and eClipboard: Patients can pay co-pays,schedule appointments, and receive directions to important clini-cal locations with the MediKiosk and eClipboard (www.ncr.com).The system does not collect clinical or demographic data. TheeClipboard is a wireless tablet version of the MediKiosk.

PatientPoint Patient Kiosks: These patient-facing kiosks offerpatient check-in capabilities including the gathering of demo-graphic data, performing E&B checks, and collecting patient pay-ments. PatientPoint (www.patientpoint.com) also offers an onlineportal that is accessible through a computer or a mobile device.

—RD

“[The system] flags a patient’s record if it notices that their information has

changed since their previous interviews.”— Shari Crooker, RN, Gwinnett Center Medical Associates,

Lawrenceville, Ga.

MULTIPLE CHECK-IN SYSTEMS OFFER VARYING FUNCTIONS

Continued on page 10

The messaging is specific to thepatient’s complaint or health status, andis intended to help the patient managehis or her health.

“It works more on their medical com-plaint,” says Crooker. “If a patient comesin for diabetes, at the end of the inter-view, he might see sponsored messagesfor diabetic medications or cholesterol-lowering medications, since those twoconditions typically go hand in hand.The patients can choose to look at thatinformation or they can skip it.”

Maximizing CollectionsThe PhreesiaPad is a 128-bit,encrypted wireless device.“It’s a HIPAA [HealthInsurance Portability andAccountability Act] compli-ant check-in process,” saysO’Leary. “It’s also PCI DataSecurity Standards compli-ant, which is a paymentindustry standard. It’s verysecure.

“With Phreesia, you don’thave capital expenditure, andyou’ve got something that can affectyour receivables right away,” O’Learycontinues. “It’s really different from thecapital outlay and the implementationprocess associated with an EMR.”

“They sent me four pads to beginwith, but we’re up to 10 pads now,” says

Crooker. “It’s pretty self-explanatory touse. We’ve had to teach some of ourfront office people about entering cred-it card data, like if somebody’s card isdemagnetized.” Beyond this basictraining, there was no educationrequired for the staff at Gwinnett to getup to speed with the devices.

The setup process was quick andeasy, Crooker says, and it did not dis-rupt the practice’s operation. “ThePhreesia representative was only herefor a little while,” she says. “Probably 30minutes or less. And the company hasexcellent customer service. If we send

them an e-mail requesting that some-thing be removed from one of ourinterviews, it’s gone in five minutes. Ifwe have a printer problem, they have itfixed within minutes.”

Phreesia is inexpensive to run, shesays. She cites a single flat rate to use

the system, based on the number ofpads the practice uses, along with a flat $1 per $25 charged on paymentscollected through the pads. When thenumbers are added up, this fee worksout to significantly less than the cumu-lative charges incurred when using abank’s card machine, according toCrooker. “I know to a lot of people theflat rate sounds like a lot, because witha bank or another processing center it’smore like 1.75% or 2%,” she says. “Butyou also have third-party fees andtransaction fees.” Gwinnett accumulat-ed fees of more than $27,000 in a nine-

month period with its oldcredit card processingcompany, Crooker says,compared with under$9,000 for a similar peri-od with Phreesia; she alsoreports that funds weremore quickly depositedinto Gwinnett’s bankaccount with Phreesia. Inaddition to the improvedpayment capture,Crooker also reports that

the convenience afforded by the check-in system has enabled Gwinnett toreduce its front office staffing by twofull-time positions, lowering the prac-tice’s operating expenses.�—Reported and written by Editor RevDiCerto.


Physician practices seeking to streamline their front officefunction and improve patients’ experience may wish to con-sider adopting an electronic patient check-in system. Such

systems can be used to eliminate repetitive paperwork, requestand collect outstanding patient balances and co-payments that practice staff may not always collect, perform eligibility and billing tests, and even, in some cases, collect patients’clinical and demographic data or schedule appointments,depending on the system used. The added convenience of these systems is popular with patients as well as practice man-agers, and in some cases has been sufficient to enable busy

practices to decrease their level of front-office staffing, loweringoperating costs.

“Basically, we replace the clipboard,” says Mark O’Leary,MBA, the chief marketing officer of New York, N.Y.-basedPhreesia, manufacturer of the PhreesiaPad, a popular newpatient check-in device. “We’ve all had that experience whereyou check into a doctor’s office and you’re handed the clipboardwith all the paper forms. We also, in real time, verify patients’ eli-gibility and insurance benefits. Perhaps most significantly, wealso ask patients to pay their co-pay amount and any outstand-ing balances.” —RD

PATIENT CHECK-IN DEVICES REPLACE THE CLIPBOARD

Check-in systems seek to streamline the patient check-in process…. Some include other advanced

capabilities, such as the ability to collectpatients’ demographic data and offertargeted messaging related to theirhealth status and conditions.

TECHNOLOGY



Most companies and even agrowing number of medicalpractices recognize that

social media have become establishedas a viable business tool. Many effectivemedical practices and a large numberof businesses are using sites likeFacebook, Twitter and LinkedIn toconnect to their customers, recruit fol-lowers and promote their services inreal time. However, medical practiceshave yet to realize the opportunity to

“connect the dots” and utilize socialmedia in a safe and meaningful way.Whoever achieves this goal first has theopportunity to revolutionize and forev-er change the medical industry.

Reaching Patients and PeersSocial media sites for the medicalindustry range from broad, open plat-forms to niche, narrowly concentratedforums. Facebook, Twitter andYouTube have become broad platformsfor individuals and corporations aliketo broadcast experiences and opinionslarge and small. Web sites such asCancerDoc (http://cancerdoc.blogspot.com), HealthLine (www.healthline.com), and RevolutionHealth(www.revolutionhealth.com) are morenarrowly targeted venues for rapidlycommunicating and connecting tousers who are sharing similar experi-ences. They offer medical professionalsthe opportunity to communicate infor-mation and share ideas with patientsand medical industry peers. ExpertQ&A sites such as WebMD(www.webmd.com) and AskDrWiki(http://askdrwiki.com) have becomepopular with patients, who can usethem to find credible information toanswer their health care-related ques-tions. Physician networks like Sermo(www.sermo.com) and Ozmosis(http://ozmosis.org) serve as “virtualwater coolers” where physicians cancollaborate in real time. Sermo, thelargest online physician communitywith over 115,000 members, serves asan exclusive forum to share medicalinsights and expertise.

But no matter what portal is beingused by a patient or a health careprovider, the single most beneficialaspect of social media is the collabora-tion enabled by the openness of vast

numbers. Most users of social mediaare trying to broadcast a message, edu-cate, inform, or simply share. The por-tals themselves, empowered by thestrength of their large numbers ofmembers, are positioning themselvesas the source of true, real-time data andinsights. Many health care facilities usesocial media to crowdsource, basicallyasking for input from users to helpthem to develop or improve productsand services quickly and efficiently.Others are enabling real-time learningby running podcasts of surgeries thatmedical students can “attend” remotelyonline.

In 2010 specifically, there was a sig-nificant jump in the number of medicalcompanies utilizing social media tools,taking after early success stories likethat of the Mayo Clinic. Mayo hasgained over 25,000 Facebook fans justin the past year (they now have over33,000). The Mayo Clinic’s “wall” isfilled with patients’ thanks, interviews,advice, industry news and nearly 150videos. Its presence in this space hasstrengthened the Clinic’s name as athought leader in medical care andinnovation.

Leveraging DataWhile a presence on social media sitessuch as Facebook and HealthLine isimportant to medical practices andhealth care companies trying to buildrelationships and brands, these buildingblocks could be the source for muchmore revolutionary advancements.Over time the intimate knowledge of acontributor, a regional demographic oran international group of sufferers of acommon condition or ailment could beused as proactive triggers for action.Imagine a device that collects signs of apatient’s general well-being, then com-

COMMUNICATIONHow Social Media Will Affect Medical Practices and the Health Care SystemBy Tim Morton, design director, Product Development Technologies

Since 2002, Tim Morton has beeninvolved with multiple design pro-jects for Product DevelopmentTechnologies (PDT), ranging fromfacilitating fast innovation work-shops to guiding in-depth researchand development programs. Hehas previously held roles withinresearch, design, marketing andsales as both client and consultant.Prior to PDT, Tim operated as anindependent consultant for fouryears in the U.K., providing cre-ative guidance and design direc-tion to multiple industries.

Continued on page 12


COMMUNICATION

bines these data with his or herFacebook postings on location, time,diet, and feeling while aggregatinginformation from other users and facil-ities. When linked to the patient’s med-ical facility and medication status, his orher pharmacy, his or her caregiver orgym, such a device could generate guid-ance and suggestions, which wouldthen be sent back the patient daily. If ahazardous situation is suspected by thedevice’s auto analysis of the data, thisdevice could directly alert the patient’sdoctor to provide personal, quickadvice and instructions. The potentialto use social media and con-nected, aware devices toenhance patients’ well-beingand preventative care ishuge, as are the possibilitiesfor predicting and trackingpatterns in health globally.

Social media offersunique opportunities forscalable interaction and collaboration.This interaction is a source of hugepotential opportunity for manufactur-ers of medical and lifestyle devices. By developing products that becomepart of the users’ daily lives (think how important your smart phone is toyou now), manufacturers will have theability to build a loyal customer base

that is not only using their device, butis also interacting with them and pro-viding unparalleled insight into theirhabits in real time, helping fuel futureunderstanding and developments inhealth care. The potential of suchdevices and such social media for col-lecting population-based health datahas only just begun to be tapped. In thefuture, the data collected and thehealth care benefits derived from themare likely to increase at a rapid andincreasing pace.

Despite all the progress over the pastyear, there remain challenges for med-

ical practices and medical device manufacturing companies when theybegin to dive into social media. Thefield is still a very new horizon for thehealth care industry. It faces numeroushurdles posed by the traditions of boththe health care industry and the insur-ance industry. Medical practices andmanufacturing companies that are

agile and able to pivot in response tothe times and the data they gatherusing social media will likely be moresuccessful than their less tech-savvy competition in the future. It isnot difficult to imagine Google as theCenters for Disease Control’s leadinginformation source in the future,aggregating and reporting data culledfrom clusters of users searching for keydisease symptoms through an app por-tal or tweeting about their chronic ill-nesses. Used as tools that can serve astriggers for health care activity, socialmedia can serve to take the tempera-

ture of societal health,allowing the health carecommunity to observe ashealth-related patterns,such as the effects of pollu-tion in specified areas of thecountry or the effects ofpopulation density andsocioeconomic variations

around the world, unfold. If device manufacturers and the

medical community find a way to har-ness and leverage the power of people’sdesire to connect and share theirhealth-related data, they could achievegroundbreaking contributions tohealth care and the connected world asa whole in the coming years.�

Medical practices have yet to realize the opportunity to “connect the dots”and utilize social media in a safe

and meaningful way.

As medical practices and manufacturers of medical devicesbecome more accustomed to using social media such asFacebook, HealthLine, and AskDrWiki, they are increasing-

ly capitalizing on social media’s ability to gather patients’ health-related data. At the same time, patients are growing increasing-ly accustomed to sharing such data. Ultimately, these data mightbe put to use on a large scale, as patients and other social mediausers provide growing amounts of information about their healthstates and their daily activities.

One example of a company that has been quick to the punchwhen it comes to bringing more innovative approaches to apply-ing data gathered through social media to improving patients’well-being is Nike. The Nike+ Running Monitor is an application

that meshes telehealth devices with social media. The devicemonitors and posts information about users’ running habits andexperiences on Facebook. All of this tracking and communicationof patients’ fitness and wellness data also serves as a great pro-moter of the manufacturer, since Nike’s product is advertisedevery time the user uses it to post a status update. The healthcare system gains data on the patient’s behavior, which couldultimately be used in the patient’s primary care physician’s prac-tice when advising the patient. In the end, both the experience ofposting the exercise information and the feedback provided bythe patient’s physician serve to encourage the patient in his orher healthful behavior.

—TM

FUTURE MEDICAL DEVICES MAY ENCOURAGEHEALTHFUL BEHAVIOR WHILE COLLECTING HEALTH DATA



T he Centers for Medicare &Medicaid Services (CMS) inJune proposed rules that will

enable consumers and employers toselect higher-quality, lower-cost physi-cians, hospitals and other health careproviders in their area. The new ruleswill allow organizations that meet cer-tain qualifications access to patient-pro-tected Medicare data to produce publicreports on physicians, hospitals andother health careproviders. Thesereports will combineprivate sector claimsdata with Medicareclaims data to identifywhich hospitals and doctors provide thehighest quality, most cost-effective care.This initiative is made possible by theAffordable Care Act, in an effort toimprove care and lower costs.

For many years employers, con-sumers, providers, and quality mea-surement organizations have been frus-trated with the limited and piecemealavailability of health care claims data.This has led many health plans to createprovider performance reports basedsolely on the health plan’s own claims,which often represent only a small pro-portion of a provider’s overall practice.

Increasing TransparencyThe proposed rules seek to change thequality measurement landscape in away that increases transparency for allstakeholders. “Qualified entities” thathave the capacity to process the dataaccurately and safely would be requiredto combine the Medicare claims provid-ed by CMS with private sector claimsdata, to produce quality reports that aremore representative of how providersand suppliers are performing. Thereports will help employers and con-sumers better understand the relative

performance of providers in their area.These rules include strict privacy andsecurity requirements for entities han-dling Medicare claims data.

This new program would provide forthe following activities:• CMS would provide standardized

extracts of Medicare claims data fromParts A, B, and D to qualified entities.The data can only be used to evaluateprovider and supplier performance

and to generate public reports detail-ing the results.

• The data provided to the qualifiedentity will cover one or more specifiedgeographic areas.

• The qualified entity would pay a feethat covers CMS’s cost of making thedata available.

• Qualified entities would need to haveclaims data from other sources.

• Publicly reporting the results calculat-ed by the qualified entity is importantfor transparency in health care andconsumer empowerment. To preventmistakes, qualified entities must sharethe reports confidentially withproviders and suppliers prior to theirpublic release.

• Publicly released reports would con-tain aggregated information only.

• During the application process, quali-fied entities would need to demon-strate their ability to govern the access,use, and security of Medicare claimsdata. Qualified entities would be sub-ject to strict security and privacyprocesses.

• CMS would continually monitorqualified entities. Entities that do notfollow these procedures risk sanc-

tions, including termination from theprogram. Comments are welcome on this set of

proposed rules.

Protecting PatientsThese proposed rules are the next stepin CMS’s effort to improve health carequality and ensure consumers haveaccess to the best available information,using new tools provided by the

Affordable Care Act. TheHospital Value-BasedPurchasing initiative willreward hospitals for the quali-ty of care they provide topatients covered by Medicare

and help reduce health care costs. Thisinitiative will be based on quality mea-sures that hospitals have been reportingto the Hospital Inpatient QualityReporting Program since 2004, which isposted on the Hospital Compare Website (www.healthcare.gov/comare/index/html).

The Partnership for Patients is bring-ing together hospitals, doctors, nurses,pharmacists, employers, unions, andstate and federal government commit-ted to keeping patients from gettinginjured or sicker in the health care sys-tem and improving transitions betweencare settings. CMS will invest up to $1billion to help drive these changes. Inaddition, proposed rules allowingMedicare to pay new accountable careorganizations to improve coordinationof patient care are also expected toresult in better care and lower costs.This proposed rule will complementthe current effort to improve quality,lower costs, and improve health by pro-viding consumers and employers amore accurate picture of provider andsupplier performance.

The proposed rules can be viewed athttp://tinyurl.com/9qjrg.�

HEALTH CARE REFORMProposed CMS Rules Seek to Lower Care Costs Through Increased Transparency

This initiative is made possible by the Affordable Care Act.


PRACTICE MANAGEMENT NEWSAHRQ Report Finds Disparities in Care Between States

NCQA GRANTS PCMH RECOGNITION TO 14 FEDERAL FACILITIES

Areport released in May from The Carter Center in Atlanta,Ga. (www.cartercenter.org), and the Philadelphia, Pa.-based American College of Physicians (ACP; www.acpon

line.org), “Five Prescriptions for Ensuring the Future of PrimaryCare,” argues that an overhaul of the primary care education sys-tem, including adopting more rigorous training in mental illnessdiagnosis and treatment, is necessary to fully implement reformof the U.S. health care system.

Common themes from the report include changing curriculums

and teaching to provide more training in team-oriented settings and to integrate behavioral health care diagnosis andtreatment into the primary care setting; leveraging existing funding mechanisms and creating new incentives to facilitate greater adoption of primary care careers among young health professionals; and stimulating a broader researchagenda to inform primary care practice and health training of the future.

The entire report can be accessed at http://tinyurl.com/6z2cmcp.

REPORT SUGGESTS CHANGES TO PRIMARY CARESYSTEM, INCLUDING MENTAL ILLNESS DIAGNOSIS

States are seeing improvements inhealth care quality, but dispari-ties for their minority and low-

income residents persist, according tothe 2010 State Snapshots, a reportreleased June 1 by the Rockville, Md.-based Agency for Healthcare Researchand Quality (AHRQ).

New Hampshire, Minnesota, Maine,Massachusetts and Rhode Islandshowed the greatest overall perfor-mance improvement in 2010. The fivestates with the smallest overall perfor-mance improvement were Kentucky,

Louisiana, New Mexico, Oklahomaand Texas. Among minority and low-income Americans, the level of healthcare quality and access to servicesremained unfavorable. The size of dis-parities related to race and income var-ied widely across the states.

The report shows whether a state hasimproved or worsened on specifichealth care quality measures. For eachstate and the District of Columbia, thistool features an individual perfor-mance summary of more than 100measures, such as preventing pressuresores, screening for diabetes-related

foot problems and giving recommend-ed care to pneumonia patients. It com-pares each state to others in its regionand the nation.

The report is based on data from the2010 National Healthcare QualityReport and National HealthcareDisparities Report, which are mandatedby Congress and produced annually byAHRQ. Data are drawn from morethan 30 sources, including governmentsurveys, health care facilities andhealth care organizations. The reportcan be accessed at http://statesnapshots.ahrq.gov.

Fourteen federally qualified health centers are the first feder-al sites to earn National Committee for Quality Assurance(NCQA) Recognition under the Health Resources and Service

Administration (HRSA) Patient-Centered Medical/Health HomeInitiative. By meeting NCQA requirements as patient-centeredmedical homes (PCMH), these centers have brought a provenmodel of high quality primary care to facilities serving some ofAmerica’s neediest residents. Three Northwest Health Servicessites in Missouri and 11 Hudson Headwaters Health Networksites in New York earned PCMH Recognition.

The HRSA Patient-Centered Medical/Health Home initiativepays the costs of federally qualified health centers, communityhealth centers and military treatment facilities to become NCQA

medical homes. However, Hudson Headwaters Health Networkalso received support from the New York State Department ofHealth and from seven other private insurers through a state-sponsored multi-payer medical home initiative.

PCMHs emphasize care coordination and communication.Research shows that PCMHs can lead to higher quality and lowercosts, and improve patients’ and providers’ reported experiencesof care. More than 2,024 practices and 8,300 clinicians in the pri-vate sector have earned PCMH Recognition. Federal facilitiesseeking PCMH Recognition must meet the same standards as pri-vate sector facilities. To comply with federal contracting rules,application and review procedures are different.

IOM Report: Use New Data Sources, Methods to Ensure Accuracy of Geographic Adjustments to Medicare Payments


Geographic adjustments toMedicare payments are intend-ed to accurately and equitably

cover regional variations in wages,rents, and other costs incurred by hos-pitals and individual health care practi-tioners, but almost 40% of hospitalshave been granted exceptions to howtheir adjustments are calculated, findsa new report from the Institute ofMedicine (IOM). The rate of excep-tions strongly suggests that the mecha-nisms underlying the adjustments areinadequate, noted the committee thatwrote the report.

The rationale for fine-tuningMedicare payments based on geo-graphic variations in expenses beyondproviders’ control is sound and shouldbe continued, the committee conclud-ed. However, several fundamentalchanges to the data sources and meth-ods the program uses to calculate theadjustments are needed to increase theaccuracy of the payments.

Medicare payments to hospitals and

health professionals working in privatepractice topped $500 billion in 2010,according to Congressional BudgetOffice estimates. Federal law requiresgeographic adjustments to be budgetneutral; any increase in the amountpaid to one hospital or practitionermust be offset by a decrease to others.

Salaries and benefits make up one ofthe largest costs of providing care. TheMedicare program should use healthsector data from the Bureau of LaborStatistics (BLS) to develop its indexesfor calculating wage adjustments forhospitals and private practice healthprofessionals, the report says. BLS dataare a more accurate, independent, andappropriate source than the hospitalcost reports, physician surveys, censusdata, and other information currentlyused, the committee said. Congress willhave to revise a section of the SocialSecurity Act to enable this change.

The full report can be viewed athttp://tinyurl.com/5uffzwe.

The Alexandria, Va.-basedAmerican Medical GroupAssociation (AMGA; www.amga.

org) on June 6 released comments onproposed regulations for Medicare’saccountable care organizations (ACO)program. While AMGA supports theACO concept, it offered suggestions bywhich to strengthen it.

The changes suggested includedallowing ACO participants to elect ret-rospective or prospective patient attri-bution; lowering the minimum savingsrate to 1%; allowing a participationtrack with only shared savings riskassumption; dropping “opt-out” provi-sions for patient data sharing; increas-ing the shared savings rate and themaximum payout cap; using riskadjustment in a dynamic fashion; sim-plification of the application process;moderation of the reinsurance provi-sions; and dropping the number ofquality measures required and phasingthem in over time.

The full document containingAMGA’s comments can be viewed athttp://tinyurl.com5utthvk.

AMGA SUGGESTSCHANGES TO ACOPROPOSED RULE

The American Medical Association (AMA; www.ama-assn.org) on June 3 submitted comments to the Centers forMedicare and Medicaid Services (CMS) on their proposed

rule regarding Medicare accountable care organizations (ACOs).The AMA expressed support for developing and testing ACOs asone of various payment and care delivery innovations, but urgedCMS to make changes to the proposed rule to allow all interest-ed physicians to participate.

The AMA offered constructive changes to the proposed pay-ment and risk structure of ACOs to encourage participation byphysicians in all practice sizes, including providing a paymentoption that does not require shared loss and allowing groups to

receive a percentage of all savings achieved.The AMA urged CMS to revise the requirements placed on

ACOs, including reducing the mandatory percentage of primarycare physicians who must be using electronic health records bythe second year. The AMA also recommended changes to qualitymeasures and reporting requirements, including allowing ACOs toreport on a lower number of quality measures most relevant totheir patient population and ensuring that the data used to cal-culate quality measures are updated and transparent.

The AMA submitted comments in late May to the Federal TradeCommission and Department of Justice regarding their proposedpolicy on ACOs.

AMA CALLS ON CMS TO REVISE ACO PROPOSAL

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