Tuesday, May 28, 2013

Why Physicians are better than Nurse Practitioners (and Physician Assistants


The big difference between Physicians and Nurse practitioners (and Physician Assistants) is NPs really do not stay with a practice for any period of time. They are a transient (I am speaking in general) work force. Most NPs, and PAs only stay practices for a short period of time, and then on to the next practice. Physicians sign contracts, and become part of the community, and act in a manner that will grow a practice.

Then there is the education and training. We all know the time and sacrifice a would-be physician puts into becoming a practicing doctor. Although the NP and PA have a rigorous training program the difference is vast.

I want to see a doctor, get diagnosed, and treated. There is a place for NPs and PAs, but playing Doctor is not a THAT place!

Nurse Practitioners Playing Doctor More Often

May 27, 2013 4:45 AM EDT

With Obamacare on the horizon and a growing shortage of primary-care physicians rising fast, nurses could fill the void. But, ask Daniela Drake, MD, are they good enough?

When I was 36 weeks pregnant, my nurse practitioner told me I had a urinary tract infection and prescribed an antibiotic. I didn’t have symptoms, so I didn’t believe her. But it was Friday at 4:30 and I got the feeling that she was in a hurry. “You increase your risk of miscarriage if you don’t treat,” she said as she dashed off a prescription.

Dr. Rebecca Parker looks at a list of patients in the emergency room of Chicago's Advocate Trinity Hospital. Emergency rooms, the only choice for patients who can't find care elsewhere, may grow even more crowded as newly insured patients will visit ERs for both real emergencies and problems that could be handled more cheaply in doctor's offices. (Kiichiro Sato/AP)

At a follow-up appointment three days later, the doctor discovered that this urinary tract infection was not an infection at all, but preeclampsia—a condition that can cause stillbirth and affects the mother’s brain and kidneys. I was losing massive amounts of protein in the urine, which the nurse interpreted as an infection. But I didn’t just have failing kidneys, I also had neurologic symptoms.  I was obviously trembling and confused.  The nurse missed it. The doctor didn’t.  I was rushed into a caesarian-section and delivered a healthy baby girl.  But if my follow up appointment had been a few days later, I might have had a seizure and died.

Despite my personal experience with one nurse’s questionable competence, as a physician, I welcome nurses into the ranks of primary-care providers. It’s not because I think they’re so caring (mine seemed to care more about going home); it’s not because I think they’re so excellent (see above)—it’s because there are simply too few primary care doctors to meet demand. During the next few years, thanks to President Obama’s Affordable Care Act, some 36 million newly insured patients will flood into the healthcare market. By 2015, according to the Association of American Medical Colleges, the United States is expected to have a shortfall of 62,000 physicians—and during subsequent years that shortfall will only get worse.

Due in part to the impending shortage, the Institute of Medicine (IOM) proposed that nurse practitioners provide primary care to bridge the gap in physician coverage. But the concern is—given my experience and that of other patients—will it work? Are nurses good enough?

Certainly nurses believe they are fully up to the task. Last week, The New England Journal of Medicine published a study stating that nurses believe they should have the same privileges and pay as physicians. Nurses also believe they will provide better and safer care. Not just good care. Not equal care. Better care. Safer care.

Doctors, of course, would disagree. Even though a well-respected meta-analysis has shown no appreciable differences in health outcomes between doctors and nurses, many physicians worry that nurses may overlook serious illness. It certainly happened to me. But I would argue that that’s the nature of medical care. After all, doctors are famous for making mistakes.  I can easily imagine my story flipped on its head:  A harried and exhausted doctor dismisses the twitching, overweight pregnant lady--who would be saved three days later by the nurse who had the time and energy to care.

What’s really happening is that American physicians are over-trained for run-of-the-mill primary care. Of course nurses can do it. I sometimes joke that a properly motivated high-school student could do it with a smartphone and a checklist. The current standard of care is medicine-by-protocol. The work is ceaseless and routine to the point of tedium—and almost half of primary care physicians are burnt out. Nurses are probably quite justified in criticizing what they see. But that doesn’t help physicians accept them.

Especially since, generally speaking, a lot of doctors are still chafing from the treatment they received at the hands of these nurses during residency training.

The rancor between our two professions is heightened by an obvious bias towards nurses in the media.  It makes a good story to portray nurses as victims of unfair, bloviating physicians. Doctors Doubt Nurses Skills, Survey Finds  trumpeted one of many similar headlines reporting this NEJM study. But that headline could have also easily lamented: Nurses Doubt Doctors Abilities, Resent Salaries.

This media bias has a corrosive effect on our dialogue—and this doesn’t help us get to a much-needed solution—because in some ways nurses and doctors aren’t all that far apart. A closer look at the NEJM study shows a startling amount of agreement. Most doctors and nurses agree that nurse practitioners can improve access to care. Moreover, an astounding 20 percent to 25 percent of doctors actually agree that nurses will provide safer, better and more cost-effective care.

Even I, despite my near-death experience, esteem nurse practitioners highly. I’ve found them pleasant, competent and collaborative. I am, however, troubled by the nursing conceit that they’re superior to physicians. That vanity certainly will create a lot of resistance amongst many doctors. And I wonder how their high self-regard will affect their ability to practice medicine. Even most nurses agree that the best providers are the least arrogant. Great clinicians continually develop their craft by learning from nutritionists, naturopaths, acupuncturists, as well as nurses.  Indeed, if we’re going to improve outcomes, our healthcare system needs to find a way to fully encompass these different perspectives.

In the end, however, we don’t have time to fight. Obamacare finally goes into effect next year and the medical system will need more providers to serve the newly insured. With fewer young physicians opting to go into primary care, many believe that in the future only nurses will be providing this basic entry-level care. After all, it’s an extremely demanding and largely unappreciated job. So unappreciated that even nurses think they can do it. And at this point, it’s pretty clear that they can.

 

Tuesday, May 21, 2013

PHYSICIANS SALARIES ARE TOO HIGH! YOU MUST BE CRAZY!


Note to the author of these article: You are a Veterans Administration Primary Care clinic FP. What do you see…maybe 10 patients a day? Go get a real job, then talk about what a hard working physician should be paid! Oh yeah buddy….while your writing about the pay differentials in Canadian, Australian and British physician when compared to U.s. Physicians you left out one very important point…..The cost of college, med school, and the low pay of the U.s. resident and fellow! British, canadian, and australians pay a very low cost (in dollars and pounds) to become Medical doctors. the average U.S. physician is saddled with $250 in med and undergraduate loans. chew on that….



|8/21/2012 @ 1:53PM |22,964 views

It's Physician Pay, Stupid!


In 2006, health-care expenditures in the U.S. rose 6%, a rate of growth significantly higher than inflation and one that, if sustained, would lead to a doubling in health-care spending in a mere dozen years.  Some of that extra spending was a function of more doctors doing more things to more people—an increasing number of hip replacements, for example, for senior citizens hobbled by degenerative joints; more diabetes and blood pressure treatments too, for all the increasingly obese people in the country whose health is threatened by cardiovascular disease.

But according to a Price Waterhouse Coopers analysis, 75% of that growth was a result not of an increase in the volume of medical interventions but, instead, an increase in their price.

People like me who obsess about our nation’s crippling medical expenses often focus on reducing unnecessary medical tests and procedures.  The folks at Dartmouth, who run the Dartmouth Atlas, correctly worry about unjustifiable variations in the use of medical procedures, with some regions of the country two or three times more likely to, say, perform C-sections than other areas.  This medically unjustifiable variation in the intensity of care, we are told, points us toward potentially vast savings.  If we can figure out how to identify unnecessary C-sections for example—or tonsillectomies or hip replacements—we can dramatically reduce health-care spending.

But overlooked in all this talk about unnecessary procedures is the unnecessarily high cost of most procedures.

Why does hip replacement in the United States cost $4,000, while costing less than half that amount in Australia, hardly a medical backwater?  Why does such an operation cost six times as much in the United States as it does in Canada?

The price of medical services is significantly higher in the United States than other parts of the world.  Primary care physicians in the United States make $186,000 per year on average versus $131,000 in Germany.  Orthopedic surgeon pay ranges from a high of $442,000 in the United States, to $324,000 in the UK, to a relatively parsimonious $187,000 per year in Australia, that according to analysis by the United Health Group Foundation.

I realize that questioning physician income will raise the ire of many physicians.  As a primary care physician myself, I have long felt that we non-proceduralists are underpaid, in comparison to our sub-specialty peers.  And no doubt, buried in the average primary care income of $186,000 per year in the U.S. are way too many hard working general pediatricians making closer to $80,000 per year.  But even highly paid doctors won’t like what I’m saying.  I expect my orthopedic surgeon colleagues will recoil at the thought that they, with all their advanced training, aren’t worth what we pay them.

But the fact remains that U.S. health-care expenses are bankrupting our country.  And there is no way to control these expenses without limiting physician pay.

 

Tuesday, May 14, 2013

Obamacare has new and serious challenge! All tax bills must originate in the House of Representatives (not in the Supreme Court)


Rules are rules…and laws are laws! Says in the U.S. Constitution that all revenue-raising laws and taxes must originate in the House of Representatives. The Supreme Court declared it a tax, but this was not a tax bill that originated in the House. Sets the stage for a new (and procedural) revenue challenge!

By Joe “ The Plumber” Wurzelbacher

Breitbart News

This is important: America needs a hero, and the Doctor is In.

To prevent the enforcement of the Affordable Care Act in Texas, Dr. Steve Hotze, a Houston physician announced he is suing the federal government, claiming the ACA violates federal tax law as written.

 

The suit claims that ObamaCare radically hikes small-business costs, impoverishes states and violates the plain language of the U.S. Constitution.

The lawsuit was filed Tuesday in Houston, Texas. The case is Hotze v. Sebelius, 4:13-cv-1318, U.S. District Court, Southern District of Texas (Houston).

Although the Supreme Court ruled the bill to be Constitutional, the majority opinion offered new hope for the majority of Americans who want it repealed. Some background:

In June of 2012 The Supreme Court upheld most of the bill commonly known as “ObamaCare” as being Constitutional, but Justice John Roberts, writing the majority opinion went out of his way to say that the program was in fact a tax and not the Supreme Court’s business.

Everyone across the spectrum reacted emotionally to the ruling. Liberals cheering their unlikely Supreme Court hero, and frustrated conservatives, who thought ObamaCare was on the way out derided the Justice -- some even labeling Roberts a “traitor,” and a “coward.”

But the opinion has opened the door to another Constitutional challenge, which will also highlight the way the bill was rammed through Congress. At the time, Nancy Pelosi (not that she read it) was not treating it like a tax and since ObamaCare did not originate in the House. Justice Roberts defining the bill as a tax meant he was throwing it back into the water for a do-over. In a nutshell, to correctly challenge the law, it must be challenged as the tax that it now is.

Was Roberts more concerned with protecting Americans from Big Government interpretations of the Commerce Clause? Was he giving a wink and a nod to the States that they need to be protected from that same ever-growing, and overreaching federal government? In any event, Justice Roberts wrote the Supreme Court ruling, talked a gaggle of liberal justices into signing onto it, and made the whole thing look non-partisan in the process.

Roberts refused to legislate from the bench. He threw the matter back to the legislature that is responsible for empowering legislation. Roberts knew Obamacare was unconstitutional as a tax, but not as it was brought before the Court at the time. He cleverly set the stage for a successful appeal.

And it’s here, thanks to Dr. Steve Hotze

“What we were promised was a new health care policy and change that could be good for all Americans,” Hotze said at the state Capitol, surrounded by Republican legislators. “Really, all it’s turned out to offer us is higher premiums, higher taxes and a government that will allow its bureaucrats to interfere with the doctor-patient relationship.”

His lawsuit offers two constitutional challenges: First, the Affordable Care Act is in clear violation of the rule requiring tax-bills to originate in the House. The original bill if you can believe it, was a tax credit bill for veterans. Secondly, ObamaCare is in violation of the Fifth Amendment by compelling the purchase of health coverage.

It is forcing individuals and businesses to purchase a consumer product -- in this case, health insurance.

Hotze’s lawsuit claims that by forcing Americans to buy private insurance, Obamacare violates the Fifth Amendment’s Takings Clause, which holds that private property can only be taken for a “public use” and with just compensation for the property owner.

The suit also claims that the Affordable Care Act is unconstitutional because revenue-raising laws and taxes must originate in the House of Representatives. In the 5-4 decision upholding Obamacare, Chief Justice John Roberts ruled that the law’s penalty on the uninsured is a tax.

"It is imperative that Texas challenge this unwarranted federal overreach and ensure that Texans maintain the most innovative and economically viable health care system in the country," he wrote in a statement.

Tuesday, May 7, 2013

Urgent Care Centers….Wave of the future! Good Care, low price…what could be better!


I see this as the future of our community care. Let’s say you cut your finger, and need a stich or two; just head on over to your nearby Urgent Care Center! $116 later your good as new! Now…if you were to head over to the Hospital’s ER that same $116 could easily climb to $1,000.

For Physicians that are seeking to run their own small business the Urgent Care model is tempting!

 

Urgent Care Centers, a Merging Trend in Health Care

By Lucia F. Bruno, J.D., LL.M., M.B.A.

Urgent care medicine has emerged as one of the fastest growing specialties in the United States.  Many family practitioners view this new form of health care as a convenient compromise to the traditional practice of medicine; absent the time and travel between offices, nursing homes and hospitals.  Likewise, emergency room physicians perceive urgent care medicine as a viable way to use their triage skills without the stress associated with a hospital setting. With approximately 8,700 urgent care centers (UCCs) nationwide and an increased percentage throughout Pennsylvania and New Jersey, many physicians question the financial incentives and legal complexities unique to this practice of medicine.  This article will address some of these growing concerns.

Ownership Structure:  Choose Your Destiny Wisely

Innovation is the principle source of differentiation and competitive advantage; innovative structuring of a UCC is no exception.  Amongst the plethora of buyouts, mergers, acquisitions, and joint ventures, investors need to weigh structuring options and management models carefully, as future profitability swings in the balance.   

Currently, only a select number of states require physician ownership of UCCs: Texas; California; Ohio; Colorado; Iowa; Illinois; New York; and New Jersey.  The 2010 survey released by the Urgent Care Association of America (UCAA) indicates that physician or group physician ownership accounts for approximately 50% of structuring, with the remaining as follows:  Hospitals 27.9%; Corporations 13.5%; Non-physician individuals 7.7%; and Franchises 1.0%.[1]

So what makes one ownership structure more profitable than another? Hospital-based UCCs are part of an existing operation; therefore, the hospital’s tax identification number is also used by the UCC which can lead to billing complications amongst other regulatory issues.[2] In contrast, freestanding UCCs are independently incorporated, maintain their own tax identification and management structure, and can bill accordingly. Although a myriad of other factors influence profitability including: overhead expenditures; reimbursement rates; and the accurate use of CTP codes; the answer to profitability lies in the fundamental accounting principal of net income, also known as net profit, (Total Revenue – Total Expenses = Net Income). This is the amount of money left in your pocket after all expenses have been paid.

When deciding which ownership structure to select, investors must balance the initiative of the UCC with the financial goals and objectives of its investors.  Regardless of structure, increasing patient volume and holding operating expenses below the level of collections will increase profitability.[3] Historically, hospital-based UCCs have failed to keep operating expenses down; as a result they struggle to break even and in the worst case scenario suffer financial loss and eventually close.[4]

Licensing:  The EMTALA Distinction

Licensing isn’t just a mere technicality; it is a precursor of how you’ll do business.  Currently, only one state, Arizona, has an Urgent Care License requirement.  Other states such as Illinois, Delaware, and New Hampshire have placed restrictions on how UCCs can be identified and marketed to the public.

In determining how to license a health care facility many jurisdictions examine ownership interest, business structure, size of the facility, and the nature of the care provided.  Since UCC practitioners specialize in the treatment of disease, illness and/or injury on an episodic basis and don’t provide obstetric services, in-hospital admissions, long term management of chronic diseases or other conditions requiring continuity of care, practitioners need only maintain state licensure necessary to practice medicine, in addition to a license to operate the lab or other diagnostic imaging equipment, where applicable.

Unlike physician-owned UCCs, hospitals may offer urgent care as an extension of the emergency department, as a fully controlled ancillary service, as an equity joint venture, or as a landlord/tenant.   Many hospital-based UCCs, or those situated on the hospital campus (or within 250 feet), are considered Type B Emergency Departments subject to specific licensing requirements, as well as EMTALA (Emergency Medical Treatment and Labor Act) statutes and JCAHO (Joint Commission on Accreditation of Healthcare Organizations) guidelines.

The Centers for Medicare and Medicaid Services (CMS) defines a “Dedicated Emergency Department” as any department or facility of the hospital, regardless of whether it is located on or off the main hospital campus, that meets at least one of the following requirements: (1)  It is licensed by the state where it is located, under applicable state law, as an emergency room or emergency department; (2)  It is held out to the public (by name, posted signs, advertising or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or (3) During the calendar year immediately preceding the calendar in which a determination is made (based on a representative sample of patient visits that occurred during that calendar year)  it provides at least one third (1/3) of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis, without requiring an appointment.[5]

It is important to keep in mind that there are three distinct parts to the third criterion set forth by CMS. In order to be categorized as a “Dedicated Emergency Department” a UCC must meet all three parts, not just one or two.  Therefore, investors must ask themselves the following: (1) are over 1/3 of the patient visits on an urgent basis; (2) without an appointment; and (3) for the treatment of an emergency medical condition?  Many will answer “yes” to the first two components, but almost all will answer “no” to the last component given the nature of care provided.  Based on the last response, those UCCs are not “Dedicated Emergency Departments” for licensing or EMTALA purposes.[6]

Regulations:  What You Don’t Know Could Hurt You

Irrespective of the applicability of EMTALA or JCAHO, there are a whole host of other federal regulations that govern the day-to-day activities of urgent care medicine.  Although ownership interest frequently dictates the regulations for which investors must comply, such as STARK and anti-kickback laws, others apply across the board.

All UCCs must comply with the privacy measures of the Health Insurance Portability and Accountability Act (HIPAA) and the security mandates of the Health Information Technology for Economic and Clinical Health Act (HITECH).  UCCs that operate a laboratory for blood tests or other related diagnoses must also adhere to Clinical Laboratory Improvement Amendment (CLIA) guidelines, in addition to Drug Enforcement Agency (DEA) mandates for the storage and dispensation of narcotics.  Finally, if the UCC provides services to Medicare or Medicaid patients, it must comply with the conditions of participation and reimbursement.   Knowing the rules of the game ahead of time can mean the difference between victory and defeat.

Coding:  Not Just a Numbers Game

One of the best ways to increase revenue in a UCC is to optimize billing and coding.  When negotiating a contract with a managed care organization it is incumbent upon UCC owners to make certain that reimbursement amounts and payment codes are specified in the contract.

CMS has designated two HCPCS (Healthcare Common Procedure Coding System) codes for UCC use: S9083 – for global fees, irrespective of the treatment provided; and S9088, an “add on code,” for reimbursement of expenses unique to the practice of urgent care medicine, such as increased overhead and wage costs.

Although these codes were never intended for submission to, or reimbursement by, Medicare or Medicaid many managed care organizations, such as United Health Care, now refuse to reimburse freestanding UCCs for anything other than professional procedure codes.[7] For those unfortunate enough to be caught up in the denial process, attempting to negotiate a reasonable compromise or a slight increase in fee schedule may be their only alternative.

Marketing to Increase Revenue:  The “Me First” Mentality

In today’s competitive economy traditional healthcare marketing strategies no longer work.   As more consumers gravitate towards urgent care medicine as a less costly, more convenient, option to traditional healthcare investors need to stay one step ahead of the competition in order to finish ahead of the pack.

Since urgent care medicine is premised on consumer choice, a successful marketing plan will focus on customer service and convenience as a top priority.   A clear vision of your goals and objectives will give you more than just direction; it will give you a marketing framework that you can build your UCC around.  A few simple strategies to effectively market your UCC are as follows:

  1. Identify your niche market:  UCCs would do well to aggressively promote services to consumers with young children by marketing themselves as conveniently located and offering extended service hours.  Other targeted audiences include local employers and HR directors interested in pre-employment physicals, drug screening and immunization programs.
  2. Set up a website:  Yellow book advertising simply doesn’t fit the mind of today’s consumer. Today, consumers search online before they do anything else; therefore, it is crucial to develop a website and list your site with several directories and search engines.  If you do not list your website, it will become an orphan site that is not known and rarely visited by revenue- generating consumers.
  3. Signage: One of the most important marketing elements is a large, well-lit, sign prominently displayed in high traffic areas.  Since zoning restrictions regulate outdoor advertising, it is important to check with your local municipality regarding restrictions before you purchase a property or sign a lease for your UCC.
  4. Free Press: The local media is an invaluable asset in marketing your UCC.  Get to know local reporters, and let them know that you are available to do interviews for TV or newspaper stories on relevant healthcare topics.  Unlike other forms of media, this is completely free and has the greatest potential to reach a mass audience.[8]

As UCCs continue to expand across the country, the fields are ripe for investors to harvest the infinite possibilities posed by this merging trend in health care.

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Lucia Francesca Bruno, JD, LLM, MBA, is Principal Shareholder of Physicians’ Legal Group, LLC (www.physicianslegalgroup.com).  She can be reached at(215) 688-3909.

 



[1] Urgent Care Benchmarking & Statistics, http://www.ucaoa.org/resources_stats.php (Aug. 2010)

[2] Tony Barber, Pros & Cons to Freestanding vs. Provider-Based Models, (Mar. 2011)

[3] Brent Cosens, Financial Lesson in Urgent Care and Occupational Medicine, (Jan. 2009)

[4] Robin M. Weinick, Phd., Renee M. Bentancourt, BA, No Appointment Needed, The Resurgence of Urgent Care Centers in the United States, (Sept. 2007)

[5] 42 CFR Parts 413, 482, and 489 [CMS-1063-F] RIN 0938-AM34, https://www.cms.gov/EMTALA/Downloads/CMS-1063-F.pdf

[6] http://www.practicevelocity.com/urgent_care/coding/type_b_ed.php

[7] Urgent Care Policy-New, UHC Network Bulletin, Vol. 29, Jan.2009, pg.3

[8] http://www.practicevelocity.com/resources/marketing.php