James Bartley

A new year yields new resolutions, so I have set some personal goals for change 2015. Here is what I hope to accomplish this year:
• Eat more green vegetables.
• Exercise at least five days per week.
• Be a better listener.
• Read more.
• Be more patient.

I also have some high hopes for how the healthcare system will change in 2015. Overall, I would like to see a national and societal recognition of what is wrong and broken in our present healthcare system and how we can address it.

1. The new Republican-controlled Congress to NOT reintroduce legislation to repeal Obamacare. Since 2011, the Republican-controlled congress has voted more than 50 times to repeal or revamp the law. The reality is the Democratic president will veto any legislation to repeal his signature policy, so why would Congress once again “spin their wheels” for something that will never happen?

2. CMS to finally realize that the meaningful use mandate has become a sole exercise in data entry. Instead of providing measurable data and improving interoperability, it has become an exercise in capturing data, not improving healthcare.

3. Physicians to be reimbursed for the quality of the visits and procedures and not the quantity of the visits and procedures.

4. Individuals to acknowledge and understand that their lifestyle clearly contributes to their health, and to recognize that they can help prevent many diseases and illnesses

5. Healthcare systems and payers to fully recognize and embrace transparency, and every patient to know what the cost of their visit, procedure, hospital stay will be before the service is rendered.

6. All electronic records to be interfaced and interoperable and have the ability to “talk” to one another. The records from a primary-care physician to be available to the specialist, the pharmacy, the lab, the imaging center, the nursing home, the rehab center, the home-care agency, etc.

7. Medical device vendors and pharmaceutical companies to have “skin in the game” and if a device or drug does not perform as promised, the consumer or the purchaser of the item, to have part of the fee/expense returned to them.

8. CMS to create national, consistent standards for Medicaid benefits and payments that eliminate state-to-state differences.

9. Third party payers to have standard pricing across the United States and a knee replacement, or a basal-cell tumor removal, to cost the same in Chicago, Boston and LA.

Now that I have generated my lists and had the opportunity to review them, I believe my personal goals for change are kind of boring. To that end, please allow me to challenge myself, with some creativity and wishful thinking. In 2015, I will:

• Learn how to fly a plane.
• Learn how to sail.
• Learn to speak Dutch - did you know that in the mid 1600s, the Dutch had more ships than any other nation in the world?
• Speaking of the Dutch, I will also buy a kayak and circumvent the island of Manhattan
- if you believe that one, I have some land for sale worth $24.

Articles

A new year yields new resolutions. Here are my personal goals for change in 2015, as well as how I hope the healthcare system will change.

Nine Healthcare Changes I Hope to See in 2015

I recently had the opportunity to travel to Annapolis, Md., for a weekend trip. Annapolis is an old historic town on the Chesapeake Bay. It is the home of the state capital, the U.S. Naval Academy, and, during the winter of 1783 to 1784, it served as the temporary capital of the United States. On my way back home, we decided to visit Fort McHenry in Baltimore, Md., which recently celebrated the 200 anniversary of the Battle of Baltimore, waged in 1814 on September 13 and September 14. That battle, part of the War of 1812 with Great Britain, is noted for the inspiration of our national anthem, Frances Scott Key’s “The Star Spangled Banner” - “Gave proof through the night that our flag was still there.” Yes, I like history.

In any event, on our way to Baltimore, we stopped at a typical strip mall diner for breakfast in the town of Pasadena, Md. While eating breakfast, my friend and I both observed and commented, that many of the patrons were - sorry to be frank - obese. I really do not know anything about the town or the area - the demographics, schools, workforce, average age, etc., but the patrons that were enjoying breakfast at the diner in Pasadena were not very healthy looking. The sad part was their children were eating the same food, and many were already obese.

A discussion regarding diet or lifestyle issues on a national level should also include a discussion on insurance, premiums, high deductibles, and also Obamacare. It is also appropriate and timely to discuss one’s individual responsibility when we all, (government, businesses, individuals), pay a lot of money for healthcare.

Last year, the former Mayor of New York City, Michael Bloomberg, attempted to 

“implement” dietary behavioral changes

 to the citizens by banning the sale of “big gulp” sodas at New York City movie theaters. A local judge decided Mayor Bloomberg “overreached” his legislative authority level and the law was never enacted. Bloomberg did ban cigarette smoking in bars earlier in his tenure.

On a national level, the FDA recently announced it will require restaurants with at least 20 locations, to display the calorie count of food items on their menus. “While no single action can fix the obesity problem, the step we’re taking today ... is a really important one for public health,” said 

.

While one may argue that it is not the government’s responsibility to dictate lifestyle, the question stills remains, at what point should an individual take responsibility for his health, and should there be a financial incentive/disincentive to influence that lifestyle?

Numerous studies have linked poor diet, cigarette smoking, lack of exercise  to diabetes, coronary heart disease, cancer, etc. Why should an individual who has a healthy lifestyle, with no visits to the doctor, hospital, clinic, pay the same insurance premium as someone who has a poor lifestyle, with multiple visits to the doctor, hospital, and clinic? When I purchased auto insurance for my daughter, her premium was greater than mine since “statistically” young adults have more accidents. When someone purchases life insurance, premiums are higher for someone who is a smoker.

I would suspect that if all those folks who were enjoying pancakes/syrup with sausage, danishes, and chocolate milk at the diner in Pasadena were asked to defend Baltimore against Great Britain in 1814, the Union Jack would be flying over Annapolis and not the Stars and Stripes.

At what point should an individual take responsibility for his health, and should there be a financial incentive/disincentive to influence that lifestyle?

Higher Health Insurance Rates for Unhealthy Lifestyles? 

In addition to my full-time job as a medical practice administrator, I also teach part time at a local community college. One of my students, who knows I like to discuss politics, recently asked me, “In lieu of the Republican victories during the recent midterm elections, what is your opinion of the future of Obamacare.”

I personally do not predict any change to how Obamacare is panning out. If the Republicans attempt to push legislative change (or, as the new Republican Senate Leader Mitch McConnell once proclaimed, pull "out Obamacare, 

What is interesting is that Sen. McConnell’s state of Kentucky enrolled over 

 last year and the state had the second highest drop in the nation in the number of uninsured, going from 20.4 percent of the population uninsured to 11.9 percent. I would like to know what Sen. McConnell would tell these Kentuckians if he were to complete his “root and branch” maneuver.

I should also add that during President Obama's first year in office, not first term, McConnell stated it 

to make sure the Obama presidency lasted one term.

And politicians want to know why their approval ratings are 

 gained healthcare coverage last year. The number of uninsured nationally dropped from 18 percent to 13.4 percent.

Sen. McConnell may not feel enrollment success is a relevant measure of program success, but enrolling over 10 million individuals offers those Americans the knowledge and comfort that they and their families may be more protected from the debilitating effects of major injuries or illnesses, and potential bankruptcies.

If Sen. McConnell determines he cannot undue Obamacare, he may once again attempt to repeal the 2.3 percent medical device tax which helps fund Obamacare.

 a lobbyist for the Advanced Medical Technology Association (a lobbying group for the medical technology industry), stated, “...We’re 

 the statements from Sen. McConnell and Speaker Boehner that they'd like to [repeal] the device tax early in the next Congress."

The lobbying group claims that the first year of the tax resulted in an estimated 14,000 job cuts. However, according to 

, Ernst and Young stated that revenues for medical technology firms grew 4 percent to $336 billion in 2013, the first year the tax went into effect.

And politicians want to know why their approval ratings are 14 percent.

Staying on the theme of Washington, the requirements for the second stage of meaningful use, created and enacted by politicians and capital-based consultants and advisers, have been subjected to mounting criticism and scrutiny by physicians and administrators.

 and about one in six hospitals have successfully attested to the Stage 2 requirements. Wachter stated, “Even former supporters have taken to calling the program meaningless abuse.”

I believe that the Republican victories during the midterm elections will have little effect on the future of Obamacare. Here's why. 

Health Reform Will Continue Despite Republican Victories

I believe most of us have heard the following words of wisdom from a parent or teacher: “There is a reason why you were born with two ears and one mouth.” As a society, we may have a tendency to speak first and listen second.

That tendency can extend to the medical arena where clinicians may also not listen, or quickly by-pass the standard physical exam and reach for the latest test/technology. 

While all healthcare providers, practices, and hospitals legitimately embrace the latest technologies, the overreliance on them ignores the fact that hands on skills should never be abandoned.

 included numerous examples in which physicians reached for the technology first and failed to adequately examine patients. The article described one patient who presented in an emergency room for the third time in six weeks, showing classic signs of liver cirrhosis.

Only after a “veteran” doctor examined the patient and noticed a rapid inward pulsation under the man’s ear, did he confirm his suspicion that the man’s problems were circulatory and cardiac in nature, and not liver related.

The article speculated that the vast array of technologies has supplanted the doctor’s physical diagnostic skills, the foundation of any assessment.

As stated by pulmonologist Salvatore Mangione, associate director of the internal medicine residency at Jefferson Medical College of Philadelphia, “There has been many cases in which technology, unguided by bedside skills, took physicians down a path where tests begot tests and where, in the end, there was usually a surgeon and often a lawyer involved.”

Pediatric cardiologist W. Reid Thompson of Johns Hopkins School of Medicine noted that studies have shown that doctors do a poor job listening to a patient’s heart and lungs. “People walk around with a stethoscope not just because it looks good or is expected, but because there is information to be learned.”

There is also the convoluted reimbursement logic that third-party payers will eagerly pay for sophisticated tests, while paying poorly for the doctor’s time performing a comprehensive history and physical.

article) Arnold Relman, a former editor of the 

, described the extended time he spent hospitalized at Massachusetts General Hospital in Boston. He reported that after his discharge, while reviewing his records, he found “copious reports of data from tests and monitoring devices, but conversations with the doctors treating him where infrequent, brief and hardly reported.”

EHRs, sophisticated tests and technologies, can never replace the personal touch and care of a physician. Touching, feeling, and listening are the inherent foundation for all relationships. Medical technologies should be used to enhance the diagnostic skills, not replace them.

Recent news articles reveal how physician over-reliance on technology is getting in the way of patient care. 

When Technology Prevents Great Patient Care

 best-selling novel, “The Boys in the Boat.” It is the true story of the 1936 University of Washington eight-man rowing team that won the national rowing championship that year and then went on to capture the Olympic gold medal in Berlin, beating the host Germans. That Olympic event was noted for the rise of Adolf Hitler and Nazism - it was also renowned for sprinter Jesse Owens' winning of four gold medals, dispelling Hitler’s notion of Aryan superiority.

In addition to the rowers, the novel tells the story of the legendary craftsman/boat builder, George Yeoman Pocock, whose philosophy of teamwork sets the foundation for the rowers’ success. In the novel Pocock states, “To see a winning crew is to witness a perfect harmony in which everything is right.”

So what does this have to do with a medical practice?

A good practice is also successful when there is harmony and teamwork among the entire practice staff. The front-desk, check-out, nurses, physicians, billers, cleaning staff, all must realize there is a common goal that centers around the patient and the physician. Medicine is, and will always be, “about the docs,” but it is the teamwork of the practice staff that makes the docs successful.

The staff members at successful medical offices practice teamwork by:

• Knowing when to ask for help, such as when a receptionist asks another front-desk staff member to pick up the additional extension when the receptionist is too busy to do so.
• Sharing important information, such as when a physician discusses and shares patient information with a nurse so that the nurse can support, educate, and empathize with the patient.
• Having an open dialogue with the practice administrator, such as when a patient is having difficulty paying his copay and the staff asks the administrator if they can waive the copay.
• Keeping patients informed during handoffs, such as when transferring calls from patients to other members of the team. For instance, the staff member might say, “Mrs. Brown, let me get you the staff person who can assist you, her name is Mary. If some reason Mary is not available or can’t assist you, my name is Jane and here is my extension number.”
• Supporting each other, such as when a staff member asks a coworker how her mother is doing, knowing she was recently hospitalized.
• Reminding the physician of important patient information, such as by saying to the physician, “The last time Mrs. Smith was here, she told you her grandson was diagnosed with cancer. Don’t forget to ask her how he is doing.”
• Never saying, “I can’t do that, it is not my job; I never did that before.” Instead always saying, “How can I help you?”
• Discussing football, TV shows, Facebook, Obamacare, the kid’s soccer games, life in general, because happiness and harmony is not always about the “bottom line.”

As boat builder Pocock would say, “Good thoughts have much to do with good rowing. It isn’t enough for the muscles of a crew to work in unison; their hearts and minds must also be one.”

If your medical practice staff members aren't doing these eight things, it's time to make teamwork a bigger priority. 

Eight Signs of Great Medical Practice Teamwork

When I was a young boy (yes it was quite a while ago), my mom would send me to the corner grocery store for a loaf of bread or a quart of milk. We asked the local merchant, whose name was Benny, to put the order “on our bill.”

When I first started working in my current position as the manager of a medical practice, my check-out staff member asked if we could send a bill to a patient for a $40 copay (rather than collecting her fee at time of service). My response was, “No.” I asked her, “If you go to the grocery store for a loaf of bread or quart of milk, do you ask the merchant to bill you later?” My mom was glad I did not get that type of response from Benny, but I am certain my response to my check-out staff member was correct.

I take a similar approach when it comes to charging patients deductibles at time of service. Patients may ask that we bill the insurance company first. My response is, “No, however we will accept 50 percent before the procedure and we will expect the balance within two to three months.”

Copays, cancellation fees, and deductibles are all part of the everyday vernacular of medical practices. Insurance companies negotiate pricing with the understanding that copays are part of the contracted rate. Failure to collect that fee comes right out of the physician’s pocket.

A similar situation occurs when a patient fails to appear for his appointment. The physician has allocated time in her busy schedule, with the understanding she will be compensated for that time slot. Yes, there are valid excuses such as sick children, last minute requests from a patient’s employer, and even, “My car broke down.” However, the patients need to understand and appreciate there are commitments on behalf of both parties.

To enhance that commitment, we tell our patients there is a $50 fee for last-minute cancellations. While I am reluctant to charge that fee, and in reality, I rarely do so, the policy “sets the tone” for an obligation on behalf of the patient that we expect to be fulfilled.

I once had a patient tell me she was forced to cancel her appointment since she had a conference call for her employer at the same time. That conference call was probably very important for her and it would not be very prudent for my office to ask her to cancel her conference call, or charge her a fee. However, that appointment was important for my practice and the patient needed to understand there is a policy in place and that her fulfillment of the appointment was just as vital to my practice.

I formerly had a position at a not-for-profit, religious hospital. The organization was very proud of its founding “mission” to treat individuals who were indigent and had no one else to care for them. The CEO was fond of saying, “Without a margin, we have no mission.” While medicine is a healing, caring profession, it is still a business.

Today, that corner grocery store I frequented likely expects to be paid immediately for the loaf of bread or quart of milk. The doctor’s office should be treated the same way.

A practice administrator shares his approach to collecting patient copays, deductibles, and payment for canceled or missed appointments. 