Suz Redfearn


Many things have changed at Jim King’s Selmer, Tenn., practice since the 2003 advent of Medicare Part D, Medicare’s prescription drug benefit. For one thing, King, president of the American Academy of Family Physicians (AAFP), now makes a pointed effort to talk to his patients about whether they are actually taking their medications, especially during the last few months of the year. Because of the significant coverage gap - known as “the donut hole” - that Part D recipients experience after reaching about $2,100 in covered drug expenditures in any given year, many of King’s patients can no longer afford their drugs by November and December or even earlier. Often, they silently just go without. 

“Patients won’t get their prescriptions filled, and they don’t tell us,” says King, one of seven family physicians at Primecare Medical Center. “They can’t pay for it out of pocket, and they are embarrassed. Now we tell them before they leave: ‘If you have problems getting your medicines, call us. We will help.’” 

That’s another thing that’s changed: King - almost 30 percent of whose patients have Medicare - now stockpiles the samples that pharmaceutical salespeople leave so his practice can give them to Part D recipients who need them at the end of the year. 

Another change? King has gotten tight with the local pharmacist. That’s because he’s on the phone with him so much now. The pharmacist calls to say a patient’s drug isn’t covered under a particular Part D plan (most markets have about 50 such plans, each with a different formulary), and would King like to discuss generic equivalents? 

Then, of course, there’s all the extra time spent arguing with Part D plans, trying to make the case that a senior absolutely needs a drug that the plan doesn’t want to cover. “We spend a lot of time jumping through hoops, faxing paperwork, being on hold,” King says. 

The result: much of his patients’ visits are spent not on patient-care matters, but on managing their Part D plans’ requirements so that their bodies - and pocketbooks - can cope. 

Any practice that has Medicare patients has gone through some uncomfortable shifts lately thanks to the arrival of Medicare Part D, which has helped seniors get at least some of their drugs covered now, but has been trying for doctors, as it imposes a restrictive managed care-type structure on prescribing. 

And since, in most cases, a senior’s Medicare card doesn’t say he has Part D, the paperwork and phone call morass comes days after the patient visit, when the patient has been to the pharmacy and had his prescription turned away. 

The issue of Part D formularies is particularly troublesome to physicians’ practices, says Robert Bennett, government affairs representative with the Medical Group Management Association (MGMA). 

In a typical scenario, explains Bennett, a senior might be on five or six drugs, and it takes time and testing to figure out which among a class of drugs is best for her, as well as determining the right dosage and observing how all her drugs interact with each other. 

Under Part D, though, after a senior is stabilized on all her drugs, her plan might suddenly remove one from the formulary, so she has to pay out of pocket for it or switch to a generic version, which involves having her physician test and monitor her through the drug change. Or the plan might alter the quantity limit so that the patient can’t get her usual 30 pills for the month, but only 15. Or, if one drug in a class with no generics goes generic, there may be pressure to switch to it, with, again, all the necessary monitoring. 

And a formulary that suits a patient’s needs well this year might change completely the next year, leaving her paying large sums out of pocket, Bennett says. 

A physician can argue that a patient needs to be on a certain drug and does not do well on alternatives, or needs 30 per month, not 15, but then she must cough up myriad medical records showing the patient’s prescription history, and that process is very time consuming, Bennett says. 


“The doctor sees all of this as meddling, as micromanaging their decisions on how to treat the patient,” he says. 

In many cases, adds Vicki Gottlich, senior policy attorney for the nonprofit Center for Medicare Advocacy, physicians’ offices are having to hire new staff members just to handle the Part D paperwork burden. In other cases, doctors are charging patients for the extra time it takes to deal with formularies that appear to change randomly and appeals efforts that take hours. 


And interestingly, because of the monitoring that’s needed to safely switch to cheaper drugs, patients under Part D plans need more office visits and lab work, adds Gottlich. The push toward generics may be saving money for Part D plans, but it’s costing the Medicare Part B plans, which cover office visits. 

However, Medicare Part D looks like it’s here to stay in its current form for the time being. But doctors who have weathered the changes that Part D has brought can offer tips for not letting it get the better of your practice and your relationships with patients. Take Andrew Merritt, a partner in a two-doctor primary-care practice in Marcellus, N.Y. Rather than spending hours studying the many Part D formularies in his market, he is now in the habit of just prescribing the cheapest possible drug for all patients, no matter what their plan. 

“We don’t even look it up in their formulary,” Merritt says. “I choose the least expensive drug possible now. I write generically whenever I can.” 

If there’s a conflict with a formulary - which there usually isn’t when prescribing generics - he waits for the pharmacist to call him and tell him, and then he’ll call the plan and try to resolve it. Yes, pushing Part D plans to cover certain drugs when they don’t want to is a hassle, Merritt says, but one that usually isn’t hard to win. “Most of the time, when we fax the prior authorization to them, it is not rejected,” he says. 

And faxing is key, says Bennett. “It’s always better to fax the plan than to call,” he advises. “One, it leaves a paper trail, in case there’s a conflict. Two, they will get back to you when it works for them, so you don’t have to waste a lot of time on hold. And three, if you’re faxing, you’ve filled out a form that will give them most of the information they need, information you don’t have to hunt down when you’re on the phone with them.” 

When it comes to forms, each plan has its own that in the past doctors had to fill out when going to bat for their patients on formulary issues. To relieve the burden of having to stock all those forms, the American Medical Association and other medical practice groups came up with a standard form, a nifty shortcut that many Part D plans accept, says Gottlich. That’s the good news. 

The bad news, adds Bennett, is that if a very expensive drug is at stake and a protracted fight ensues on a patient’s behalf, many of the plans will make the doctor fill out their company-specific prior-authorization forms anyway. 

For those practices who are handling Part D by trying to stay on top of the formularies, Epocrates.com has become invaluable, says Bennett. The free Web site provides quick access to all the formularies of all plans, Part D or otherwise. But to get the most use out of it, says Bennett, doctors need to have a computer in the exam room, or at least a handheld PDA. That way, they can look up a patient’s formulary while sitting with the patient discussing a drug, prior to writing a prescription. 

Another option is doing what King does: stockpiling drug samples to help seniors at the end of the year, when most of them - 4.2 million last year - are without prescription drug coverage. (Once a senior has spent about $3,850 out of pocket on prescriptions, he is out of the donut hole and has coverage again.) 

Using samples, however, has a significant limitation, explains Jim Dearing, a member of the AAFP’s board of directors and a solo practitioner in Phoenix, Ariz. 

“Usually the samples are the expensive, brand-name drugs, which Part D recipients can’t be on anyway,” he says. Thus, giving them those samples would involve taking them off their generics, watching closely to assess how they do on the samples, and then putting them back on generics at the start of the new year, when their coverage is restored. “It’s just not doable,” he adds. 

Another option, Dearing says, is to suggest that patients get their generic drugs from Wal-Mart. The retailer recently started offering many generic-drug prescriptions at $4. Now other stores such as Target, Costco, and Kroger are following suit. Explains Dearing, if a senior with a Part D plan gets all their generic drugs this way all year, instead of going through their plan, it helps them stay out of the donut hole coverage gap longer. 

How to get patients educated on all this? Dearing suggests identifying the healthcare decision maker for the family. Is it the senior? The spouse? The son or daughter? Once you figure that out, have that person in during the patient visit while you are explaining the Medicare D changes. It may cost you some time initially, but it pays off in the end, for them and for you. 

“Taking that time up front with the key caregiver is worth its weight in gold,” Dearing says. “If you do that, you’ve got the whole family fixed.” 

Another tip: Be careful what specialists you refer to, advises King. 

He explains that most primary-care physicians are now familiar with prescribing the cheapest possible drugs for seniors on Part D - but not all subspecialists are. And often, after a visit with a specialist, a senior will call or come see his primary-care doctor flummoxed about how he’s going to pay for the expensive drugs the specialist just prescribed, Dearing says. 

From there, the primary-care physician has to call the specialist and talk to him about generics the patient might be able to take, or she may have to take over trying to fight with the patient’s plan to get the drugs. 

Why not just push that burden onto the doctor who wrote the prescription? Because then the patient might get left out in the cold, Dearing says. Ultimately, as a senior’s primary-care physician, he feels it’s his duty to coordinate all patient care and drugs, even if it means more work for him. 

“Just try to make sure you are referring to people you can work with,” he adds. 

Though Medicare Part D looks like it’s here for the long haul, there may be some revisions to it in the not-too-distant future as Congress looks at how it can be improved, says Gottlich. She predicts there may eventually be limits on how many plans can be offered in a given market, and that the appeals process may be made less onerous. 

And no doctors will argue with that, she adds. 

is a long-time health reporter who has written for the

 Washington Post, Men’s Health, Slate, Salon, 

This article originally appeared in the March 2008 issue of Physicians Practice.

Articles

We’ll let the pundits haggle over whether Medicare D is helping seniors. We’re concerned with how it’s affecting you. If changing formularies and requests for new scripts are wearing you out, try these recommendations for making things easier.

Healthonomics: Handling the Changes Wrought by Medicare D


It’s safe to say that Susan Miller is knee-deep in health savings accounts (HSAs) and the high-deductible plans that by law must accompany them. 

Miller is the administrator of Family Practice Associates in Lexington, Ky., which is not only seeing an increasing number of patients that have HSAs but also offers HSAs as an option to its own employees. 

It’s been a mixed blessing, reports Miller. 

“The physicians here really wanted to lower premium costs and give employees an opportunity to put aside more money on a pretax basis, and that has worked out great,” she says. “But as for patients coming in with health savings accounts? That has been far more difficult to administer.” 

Miller continued. “We’ve built this huge mechanism around getting paid by managed care, and now we’re going to have to get paid by patients, which is very difficult when you’re not sure what to collect, and often have a patient who’s confused or doesn’t want to pay. It becomes far more confusing because their payment is based on how much of the deductible they have met, as well as what is allowable for their particular health plan.” 

Unfortunately, none of this information is quick or easy to obtain. 

Established in 2001, health savings accounts allow consumers to put aside money on a tax-free basis to pay for their healthcare costs. By law, HSAs must be attached to a high-deductible health insurance plan. In theory, the patient uses his HSA to pay that deductible, as well as any other up-front healthcare costs, via a debit card. If not used in one particular calendar year, the saved funds can be rolled into the next year. Funds that are still there by the time the account holder is 65 can be rolled into a tax-free IRA, if the person chooses. (The HSA differs from the medical savings account, or MSA, in that the MSA is for the self-employed only.) 

The maximum allowable tax-free yearly contribution in an HSA is $2,900 for individuals and $5,800 for families. And the catastrophic plans coupled with HSAs have deductibles between $1,100 and $5,500 for singles, and $2,200 and $11,000 for families. Blue Cross and Blue Shield and United Healthcare are big players in the high-deductible market. Currently, it’s estimated that about 7.2 million people in the U.S. have consumer-driven healthcare plans. 

Samantha Rosman, a pediatrician who chairs AMA’s board of trustees’ task force for health-system reform, expressed concern that HSAs may be more appropriate for people with low yearly medical costs - a young, healthy person - than families or the chronically ill. Even so, she said the theory behind them is sound. 

“We hear they are supposed to improve physician-patient communication on the costs and benefit of procedures, which I think has been taken out of doctors’ hands in managed-care plans,” says Rosman. “The doctor and patient can decide together whether [a given treatment] is an appropriate use of the patient’s money. Doctors are looking forward to that.” 

HSAs fall under the umbrella term “consumer-driven healthcare,” which also includes health-reimbursement arrangements - basically HSAs funded by employers. Proponents of these options, in conjunction with a high-deductible plan, believe that they give consumers greater control over their health. In fact, a study conducted by management consulting firm McKinsey and Co. found that patients in such plans were twice as likely to ask about cost and three times as likely to choose a less expensive treatment option. In addition, chronic patients were 20 percent more likely to follow treatment regimens carefully. 

Consumer-driven health plans also have the potential to save the patient and the insurance company money by cutting down on the use of expensive prescription drugs, says Bill West, an OB/GYN and founder and president of First HSA, a Reading, Pa.-based company that markets and administers HSA accounts. “When patients are paying for their own drugs, they’ll ask for the generic rather than a drug that costs $600 a month,” he said. “Patients [in managed care plans] don’t know what a drug costs; they’re shielded from it by a $20 copay. And often, other drugs are just as good.” 

This saves everybody money, except the drug companies. 

Theoretically, that’s all a good thing, but while physicians make the transition from a patient population insured mainly by managed care to one with a mix of coverage types, there is some havoc to face. 

The AMA recently surveyed its members, asking whether the advent of consumer-driven healthcare plans was making billing and collections processes more difficult and/or time-consuming. Sixty-five percent believed such plans will force them to increased collections efforts, while 61 percent believe their office will now need to make more of an effort to verify benefits and train staff to do so. The AMA, says Rosman, will soon create brochures to help physicians through the transition. 

Although HSAs and high-deductible plans have been causing confusion and sometimes widespread panic in doctors’ offices lately, there are, thankfully, some fairly straightforward solutions, explains Cynthia Dunn, Cocoa Beach, Fla.-based senior consultant with the Medical Group Management Association.

One problem is that many insurance cards don’t say that the patient has a high-deductible plan or that an HSA is attached to it. Sometimes, even the patient doesn’t know; sometimes patients do know, but are unclear on what they are or how they work. The patient just hands you the card, on a busy day in your crowded office, and you must spend 15 minutes on the phone with her insurance plan trying to figure out, first of all, what type of insurance it is (high-deductible or otherwise, and after that, 80/20?), and then what is allowable (preventive services, or no?), and how much of the deductible the patient has met. 

“The answer to all this,” says Dunn, “is preregistration, plain and simple. Have the patient fill out registration forms days in advance of the visit, which enables staff to check the nature of their insurance before they come in.” 

This can be done by phone, but it’s far less-time consuming if you can do it electronically, adds Dunn. Check your software. Even if you don’t have a big, expensive EMR system, your practice management software may be equipped to check eligibility on a patient after you type in her insurance information. Some systems even do an automatic eligibility check each night on every patient who has an appointment the following day, providing notes for staff in the morning. 

If, however, you’re a primary-care physician seeing a slew of patients who just called that morning for an appointment and you’re unable to get their insurance info ahead of time, you may be able to do a real-time electronic eligibility interchange. More and more large payers are setting up systems that enable providers to sit down, type in a patient’s member number, and get eligibility info within three or four minutes - rather than spending 15 minutes on the phone. 

Dunn adds that it’s of the utmost importance to train employees to master these techniques, as doing so can relieve a large part of the headache that comes with processing HSAs and high-deductible plans. 

“These are things we should be doing anyway, but HSAs and high-deductible plans really make it necessary,” she says. 

Rosman likens HSAs with their attendant high-deductible plans to old-fashioned indemnity plans. The common denominator: collecting fees from the patient at the time of service. But many practices aren’t set up to do that anymore. 

And collection from patients with consumer-driven healthcare options can present unique 
conundrums, to wit:

Some high-deductible plans will tell patients not to pay the doctor upfront. Instead, the plan says it will eventually advise patients how much, if anything, they owe the doctor, and they can then pay that amount out of their HSA. This is a problem because, as Miller says, “The more time that elapses between the service and the bill, the less the likelihood that you’ll actually get paid.”

If practices swing in the opposite direction, though, and simply collect the cost of the entire visit’s services from a patient who has an HSA, that can hurt them in the end, said Miller. “It’s costly and time consuming to later process a bill and cut that patient a check after the insurance company says you owe them a refund.”

Sometimes patients come without an understanding of how their HSA works, and they are so unaccustomed to paying more than a copay at the doctor’s office that they balk when an actual bill is handed to them. And then staff needs to spend time explaining how it all works.

Some patients have no intention of spending their HSA money at the doctor’s office. Yes, they get the concept, but no, they aren’t parting with the money. Instead, they view it as an IRA that no one is touching. “They may say, ‘I’m sorry – I don’t have any idea what you’re talking about,’ when you ask for their HSA card, or they may claim they left it at home,” Miller says.

Although practice employees can check eligibility to discover what benefits a patient’s high-deductible plan allows, and how much of the deductible has been met, they can’t check the balance in a person’s HSA. So, if a patient opts for a costly procedure that’s not covered under their insurance plan, and their HSA doesn’t have enough money to cover it, the practice may have a hard time collecting it. 


Dunn says practices can try to guard against these situations by deciding on strict policies and procedures on payment, and communicating them to patients as well as posting them very clearly in the office and on their Web site. Practices may also want to post prices for services online, so there is no ambiguity about that, suggests Dunn. Again, training is key. Make sure that your staff understands HSAs and high-deductible plans, and that they are not bashful about collecting. 

For those patients who call rather than come in, Dunn suggests setting up e-visits, which allow established patients an encrypted online exchange with the doctor for a small fee - say, $25. That way, the practice is paid for its time, and the patient is happy too, having gotten the answers he wanted without paying too much. 

Consumer-driven health plans seem destined to alter the way practices handle billing, but they might also force a few other changes. For one thing, says Dunn, medical documentation is going to have to get better. 

“If a patient who is paying for their own procedures opts out of a treatment, physicians, in order to protect themselves, will have to do a much better job documenting the discussions they had about that, outlining the reasons why they wanted [the procedure] done,” Dunn says. 

Otherwise, potential lawsuit. As far as she knows, there haven’t yet been any suits as a result of such a situation, but Dunn says the possibility is definitely there. 

Another change that’s expected as a result of HSAs’ and high-deductible plans’ presence in the market: increased EMR adoption. More and more practices, confounded by the mix of payers that now, again, includes patients, will need a good EMR system to keep it all straight and flowing in a way that keeps the practice profitable. “This will definitely push people toward electronic medical records,” Miller emphasizes. 

And if Miller’s practice is any indication, HSA adoption is still quite low, appealing mostly to people who have no problem affording their healthcare and may just be looking for another way to invest. When her 50 employees and 10 physicians were offered HSAs in 2006, none of the staff opted for them - but all of the doctors did. 

“The [staff] were really concerned that if they had a serious illness, they were not going to be able to put away enough money to cover the difference in that high deductible,” she says. “It was more of a risk than they were willing to take.”

The physicians, however, were psyched. “They saw it as a way to put away more money on a tax-free basis after maxing out their 401(k).” 

is an award-winning healthcare writer living in Falls Church, Va., who for over 15 years has written for a variety of publications, including 

This article originally appeared in the February 2008 issue of Physicians Practice.

Our new occasional series on the nexus of healthcare and the changing economy begins with a look at health savings accounts. Increasingly popular with patients, HSAs promise owners the chance to have more control over how their healthcare dollars are spent. Yet they present unique challenges for your billing office.

Healthonomics: How to Handle Health Savings Accounts


It was the middle of the night, and one of Tim Baird’s patients was in the emergency room. The ER doctor treating her needed more information before he could proceed. He was pretty sure he’d be unable to obtain the answers he needed at that late hour, but he called Baird’s OB/GYN office anyway and had him paged. Baird awoke to the beeping of his pager, but rather than call the ER physician with what little information he could recall about that specific patient, he powered up his laptop and quickly downloaded her entire medical file. He was able to give the ER doc everything he needed to know to treat the patient immediately, including her updated lab work. 

“The doctor in the ER was amazed,” Baird recalls. 

But Baird wasn’t. He says instant access to his patients’ data anywhere, anytime is just one of the daily upsides to fully utilizing his practice’s electronic medical record system, which went live when his practice opened its doors in summer 2004. 

It didn’t happen right away, says Baird, but after about a year, he and his two physician colleagues at Women’s Physicians of Jacksonville, Fla., found themselves well-versed in just about every application their system offered. After all, he explains, they couldn’t afford not to. The practice spent $146,000 to implement the system, and it pays $1,600 a month on IT maintenance. 

But Baird admits that the learning curve was a steep one. 

“When you first start using your system, you’re just trying to survive,” he explains. “But after a while, several of the really nice components - the bells and whistles - start to become apparent. Then you pick the ones you’re most comfortable with, and you work hard to come up to speed on those.” 

Unfortunately, Baird and his colleagues aren’t the norm when it comes to getting the most from their EMR investment. Only about 25 percent of physicians’ offices have EMRs, and of those that do, only a small number use the majority of the applications their EMRs offer. According to Rosemarie Nelson, a health IT consultant with the Medical Group Management Association (MGMA), there is no survey that shows how many practices adopt EMRs as completely as did Baird and his colleagues - but she estimates that it’s roughly 30 percent. 

“Generally, most EMRs go unimplemented,” says Nelson. “And once fully implemented, they stall for one reason or another.” 

Why? “Change management,” she explains. 

“It requires physicians to change the way they document their visits, and that’s hard to do after years of paper charting.” 

But, Nelson adds, once a practice manages to get its physicians over that initial learning incline, the rewards can be remarkable. 


Take, for example, interoffice electronic communications - the process by which doctors and nurses communicate about patients using computers or hand-held devices while the patient in question is in the office. Most EMRs include this function or it can be added on, but few practices take advantage of it - much to their detriment, says Pam Wostarek. 

Wostarek, the regional implementation manager for Horsham, Pa.-based NextGen Healthcare Information Systems Inc., explains that a doctor employing this option can, for example, make notes on a hand-held device about a patient during her office visit and then instantly send those notes to a nurse, who may need to act on them immediately. In addition to enhancing efficiency, the device leaves an electronic paper trail. 

“Doctors are used to walking out into the hall and talking to somebody during or after a visit - but that’s not documented anywhere,” says Wostarek. “This is better for everyone.” 

Some practices that really have their EMR systems on full tilt will go a step further by adding patient flow and tasking into the mix. 


According to Don Shoen, CEO of MediNotes Corp. of Des Moines, Iowa, many EMRs, with proper manipulation, will allow physicians and their staff to track which patients are in which waiting rooms and how long they have been there. Some programs even allow doctors to view a stored photo of each waiting patient as they pass a cursor over diagrams of their various exam rooms. Knowing who is in which room eliminates the need for paper charts slipped into file holders attached to each exam room door, thus increasing patient privacy. 

These capabilities also allow doctors to enter examining rooms with a ready apology if they know a patient has been waiting for an extended time, adds Shoen. 

And subsequent tasking can flow from that point. For example, once a patient is in an exam room and waiting to see a physician, an EMR’s tasking function can automatically alert the nurse or medical assistant that it’s time to take that patient’s blood pressure and vital signs. The EMR then provides a template into which the nurse can enter the patient’s data. The system can be further configured to trigger an electronic message to the lab, telling staff there it’s time to draw the patient’s blood. After that task is completed, the doctor can receive a message on her hand-held device letting her know the patient is now truly ready to be seen. 

“This offers a lot of great office efficiency,” says Shoen. 

Of course, he adds, this is not the first stuff you learn when your EMR is being implemented, and doctors shouldn’t despair if they haven’t yet come this far. 

“The brain is like a sponge - there’s only so much you can retain when you’re first learning,” Shoen says. That’s why it’s important for doctors and their staffs to keep coming back for more training, as many EMRs have seemingly endless applications that can be applied to help practice operations flow ever more seamlessly. 

“It’s like Microsoft Word - there are tons of features that so few people even know about or take advantage of,” says Shoen. 

One EMR feature that’s allowing a growing number of practices to begin to reap benefits is preventive health and disease-management reporting. 

To take advantage of this capability, says Dan Pollard, director of product management at Misys Healthcare Systems, a practice’s staff programs its EMR to query all medical records and flag those of, say, all men over age 50. The system can then be set up to mail postcards to each of these patients informing them it’s time to come in for a preventive colonoscopy. Or, if the practice prefers, the system can merge with Microsoft Word and generate a list of names and phone numbers that staff can call to make appointments. 

“This is a very important way to leverage the power of the electronic medical record,” says Pollard. 

Flowing from that concept, adds Nelson, is the patient portal. Rather than mailing postcards reminding patients of the preventive services they are due for, many tech-savvy practices will send patients e-mails directing them to the practice’s password-protected Internet portal. 

Once they log on, patients can preregister for appointments, find out what preventive care visits they may need, and receive recent lab results complete with lay-language interpretations. 

According to Nelson, these services can speed up daily office procedures tremendously, as many overworked practices allow significant time to elapse before calling patients with lab results. Often patients call them first, which can further interrupt office work flow. Unfortunately, says Nelson, only a small percentage of practices with EMRs take advantage of the patient portal capability. It’s just one of those oft-ignored features. 

“It would facilitate office visits incredibly if doctors were able to realize the impact of communicating with patients this way,” says Lucinda Israel, also a regional implementation manager for NextGen. 


But physicians are beginning to catch on. Baird’s practice is looking into the power of patient portals now, and he hopes to go live with them by the end of the year. 

Many practices fail to use EMR features that some consider very basic - such as electronic transcribing, e-prescribing, and interfacing with labs and pharmacies. 

Nelson says using simple electronic transcription applications - an element of nearly all EMRs - allows patient visit information to be imported seamlessly into a patient’s chart, thus skipping many formerly necessary steps. The upside of doing this is undeniable, she says: “It allows doctors to increase productivity by one patient a day, and for most physicians, one patient a day across a year will pay for a transcriptionist.” 

Nelson is also a big advocate of using an EMR’s e-prescribing tools, particularly when it comes to refills. If done the traditional way, this process entails many inefficient steps, but if it is performed electronically, it happens very quickly. And everyone’s happier. 

Tee Green, president of Greenway Medical Technologies, agrees. 

“Take a traditional paper practice,” he says. “A patient calls, says he needs a refill of Allegra. Nurse pulls the chart, sends it to the doctor. Doctor approves it or doesn’t approve it. Phone staff calls the pharmacy. This can take two or three days. If the patient calls a practice with a good electronic system, though, the request is sent to the nurse electronically, who messages the doctor, who has the chart right in front of him. He approves it, and, in some systems, he can interface with the pharmacy directly.” 

Nelson says the day in which the majority of practices take advantage of most of their EMR features is slowly coming. Until then, she’s happy to witness the small victories - the occasional interest in patient portals, the willingness to dip one’s toe into electronic transcription - that are occurring along the way. 

is an award-winning healthcare writer living in Falls Church, Va., who for over 15 years has written for a variety of publications, including

You put a lot of cash into purchasing and implementing your EMR. Are you taking advantage of everything you paid for?

To The Max: Get the Most from Your EMR


The trouble started the day Robert Meacham’s accountant told him his nurse practitioners were losing him money. Meacham, the sole owner of Baxter Clinic in Hernando, Miss., was baffled. He knew he paid his three nurse practitioners reasonably well, and they certainly saw plenty of patients. 

Convinced that something wasn’t adding up, Meacham took his books to his banker, who looked only at the bottom line and sided with the accountant. Still not buying it, he hired a practice management consultant who immediately saw the problem: Thanks to Meacham’s accountant - who specialized in construction firms, not physician practices - his office’s books were an unintelligible mess of misclassified expenses. Patient insurance overpayments, for example, were lumped in the same category as premium payments for the practice’s group health insurance. Meacham’s medical supply expenses appeared - incorrectly - to be five times those of other practices the same size. And, most important, his NPs were not losing him money; in fact, just the opposite. 

“My accountant had said, ‘You don’t need all [these categories] broken down. We can simplify it,’” recalls Meacham. “His categories may have, at some point, made sense from a tax standpoint, but from a practice management standpoint, it was impossible to analyze anything, to tell how the practice was doing.” 

Experts say this is exactly what can happen if practices fail to conduct due diligence when choosing an accountant - that all-important adviser who not only addresses your tax concerns, but also helps you organize your books so you can see how your office is faring from a practice management perspective. 

Many physicians don’t know that their accounting needs change as their practices grow - a serious oversight - says David Mandell, a New York City-based attorney who has many healthcare clients. “Just like my father did when he came out of med school in 1965, young doctors just need someone to do their very simple 1040,” Mandell says. “But when things get busy - they get married, have a family, and their practice grows - they are still working with the same accountant, and that’s a mistake. How many of us still go to a pediatrician for our healthcare? It’s the same thing.” 

As your financial needs change, Mandell suggests asking either your attorney or practices similar to yours for recommendations. Are your colleagues happy with their current accounting services? Do their CPAs’ skills match their practices’ level of sophistication? Search for that perfect balance to find the right fit for your needs. 

What do you need to know, first and foremost, when interviewing prospective accountants? “Hands down, [you should ask] whether or not they have worked with other physician practices,” says Ken Hertz, an Alexandria, La.-based consultant with the Medical Group Management Association (MGMA). Accounting-wise, the medical world is nothing like other industries. Reimbursements are different, as is the chart of accounts; ditto for benchmarking and software. Hertz suggests asking detailed questions regarding the candidate’s medical practice work experience during an initial accountant interview. If the candidate has such experience, ask for those clients’ contact information, and get in touch with them. 

Ron Lamberth, a partner with the Charlotte, N.C., accounting firm Cherry, Bekaert and Holland, advises physicians interviewing accountants to ask the following: “Are those practices [you are working with] achieving the levels of profitability that practices in their peer group should achieve? Is the accounting firm familiar with MGMA’s statistics on how practices in different specialties are performing?” As he points out, “They need to be, in order to keep the practice up-to-date and on track.” 

Size does matter - a lot. Hertz recommends shying away from firms that have worked solely with practices significantly smaller than yours. “If you are a 25-doctor group and the CPA you’re considering has only ever done a one-doctor practice, when you talk about developing a sophisticated cost system, he may say, ‘I don’t have experience with that,’ or worse yet, he won’t say it and you will find out later,” says Hertz. 

Hertz says it’s imperative to determine during the interview exactly what your prospective accountant plans to do for you and your practice. Tax accounting - including quarterly payroll taxes - should be a given. But will he also go deeper, producing analytical management reports, monthly financial statements, and the like? Or will your office manager or bookkeeper take care of those tasks? Hertz says that in general, an office manager or bookkeeper should have a solid grip on basic accounting principles - including processing all the practice’s account data, posting receipts, and making payments on invoices. But you should expect an accountant to be able to help establish the underlying architecture for those functions, ensuring accuracy by instituting proper checks and balances within your system. 

At times, who handles which financial tasks can get way out of whack. Consider what happened at Physicians to Women, an OB/GYN practice in Stuart, Fla. Over a 10-year period, this five-doctor, 30-employee practice neither hired a bookkeeper nor properly delineated its office manager’s financial duties. So the practice’s accountant did it all by default. This person spent inordinate amounts of time performing office tasks that included reconciling bank statements, reviewing accounts payable, calculating revenue allocation, providing profit and loss statements, etc. Such tasks are typically outside the boundaries of a CPA’s job description, and indeed the practice was paying double for its accountant to perform services that were more appropriate for an office manager or bookkeeper. “Even our accountant told us we were spending too much money on him, and we should just get a bookkeeper,” says Peter Dayton, an OB/GYN at the practice. “But we were so busy all the time, we just got complacent.” 

The practice finally hired Hertz, who all but insisted that Physicians to Women hire a bookkeeper - which it did - thereby cutting the responsibilities (and the cost) of the accountant’s work in half. 

Tax planning certainly springs to mind when one thinks of accountants. But nowadays, accountants should be doing much more, says Mandell: “The vast majority of accountants look backwards at what happened earlier in the year. They should instead say, ‘OK, let’s see where you are now, and let’s try and implement some things so that you’re not in that position again next year and the year after that.’” 

Lamberth concurs: “You want someone who is leading the charge instead of just reacting to things the client brings. The ones that stand out now are assisting the client in planning for the future.” 

How can you tell whether a prospective accounting firm is of this ilk? Lamberth advises outlining the current financial state of your practice during the initial interview and then listening closely for any innovative planning ideas your candidate may suggest. Or just ask outright, says Hertz: “What are some specific ways you plan to be proactive in helping our firm plan for the future?” If you get a blank look in response, you’ll know this is not the candidate for you. 

Hertz says that new practices trying to start out properly - or old practices attempting to reboot - can benefit from three advisers: an accountant, an attorney, and a practice management consultant. These three professionals should work in concert with one another to ensure your practice’s financial systems are both saving and earning money. Problems can occur if any of these three advisers stops being a good team player. 

“You want to make sure none of them has too big an ego,” says Lamberth. “Some accountants may try to protect their turf,” especially if their firm offers add-on services that the practice’s attorney or consultant may already be handling. If that’s the case, the accountant may have an eye toward finding an opportunity to shoot the other advisers out of their saddles rather than cooperate with them in your practice’s best interests. (Of course, this undermining can stem from any member of the team, not just the accountant, so beware.) 

How can you assess the likelihood of such corporate competition occurring with your practice in the balance? Lamberth suggests querying your CPA candidates on their teamwork experience, especially within medical practices. Get the details on past collaborations. What was the division of labor, and who decided what that division would be? What were some of the key group tasks that benefited the practice? If the prospective accountant stumbles over her answers during the interview, you may want to move on. 

The best-case scenario? Without your prodding, the prospective CPA will volunteer to collaborate with other financial professionals. “He should be saying, ‘I want to make sure I’m part of a team of advisers for you,’” says Lamberth. “He should be bringing up the idea himself.” 

Don’t be shy about seeking a second opinion on any of your accountant’s recommendations, says Mandell. Often a second accountant will spot issues the first one missed. 

Mandell describes one such situation in which an accountant he knows was called in by a client as a second CPA. His fresh set of eyes immediately spotted an area in which the client could reduce his taxes by $2.5 million - well beyond what the first accountant had identified. “The only way to know whether or not you’ve gotten good advice is to see a second person,” says Mandell. “Your CPA is never going to say, ‘Go get a second opinion on what I told you.’ You are the only one, and it’s important to do it.” 

Also guard against over-paying for such services, advises Hertz. According to the MGMA, outside fees for professionals who assist physicians in business matters - which include attorneys, consultants, and accountants - should total 1 percent or less of a practice’s annual revenue. “If an accountant says, ‘It will cost you $75,000 for me,’ I’d make sure and run the other way unless he’s going to be your surgical assistant as well,” says Hertz. 

Both Lamberth and Mandell agree that doctors often make the mistake of delegating to their office managers or another employee the task of retaining an accountant. “The doctor shouldn’t expect that by hiring an accountant or a bookkeeper that it relieves him of all the responsibility of watching the finances,” says Mandell. “He still needs to be exercising basic controls, looking at bank statements, signing checks. He still needs to maintain oversight of the money.” 

As a physician business owner, you must walk that fine line between appropriately involving yourself in your office’s important business transactions and micromanaging them. In this case, trust your employees to do their jobs, but take a hand in interviewing prospective accountants, and always retain ultimate control over important financial decisions. It is, after all, your practice. 

is an award-winning healthcare writer living in Falls Church, Va., who has written for a variety of publications, including

This article originally appeared in the June 2007 issue of

Are you using your brother-in-law Larry to handle all your practice’s accounting? Big mistake - unless Larry happens to have a good understanding of the peculiarities of healthcare economics and can do more than fill out tax forms. Your practice is your livelihood. You need a pro.

Finance: Accountant Recount


When Larry Russell, a family practitioner in Hendersonville, N.C., recalls the best three moments in his life, he winces. They are not, in his estimation, what they should be. 

Moment No. 1, he says, was the birth of his first child, a son. 

Moment No. 2 was the birth of his second child, a daughter. 

But Russell recalls Moment No. 3 with a sigh. It was the day he learned a jury had declared him not guilty of medical malpractice after he was accused of failing to diagnose lung cancer in a patient in 1991. 

“It was a miserable time,” says Russell. “The case - which was really about a chart my associate had signed off on - dragged on for two and a half years, causing major stress. Sadly, getting the results back on that trial ended up being one of my most significant memories.” 

If you think that what happened to Russell will never happen to you, think again. Statistics show that almost half of physicians will be sued 

during their careers. The good news, say experts, is that there 

 measures to take to reduce the chances of having that happen. And those measures are not at all complicated. 

Larry Veltman, a retired OB/GYN in Portland, Ore., can relate. He was sued in 1995 when a very large baby he delivered developed shoulder dystocia. The case took five years to make it to court. During that time, Veltman says, he was a wreck any time he had to attend a deposition, take a call from his attorney, participate in a settlement discussion - or anything else that pertained to the lawsuit. As the trial approached, he even got into two small car crashes, which he blames on overwhelming stress and distraction. 

Veltman won the case, but he still shudders when he’s reminded of it: “It’s a very traumatic event that makes you think more than anything: How can I prevent this from ever happening again?” 

There are no guarantees, of course, but there are things you can do. And “it really isn’t brain surgery,” says Kenneth Hertz, senior consultant for the Medical Group Management Association (MGMA). “It involves simply developing standards and protocols so there is consistency and clarity in everything the practice is doing.” 

Peter Dayton, an OB/GYN in Stuart, Fla., who has been sued five times, puts it this way: “Put a little lawyer on your shoulder, walk around your practice, and see how that changes your behavior.” 

Malpractice attorneys say enhancing doctor-patient communication is the first cornerstone of risk management. Ask yourself: Do you take the time to really listen to patients? Do you answer all of their questions? Do you fully explain all the risks involved in procedures before performing them? Not taking care of these things as a matter of course with each patient can land you in a heap of trouble. 

“After doing this for more than 20 years, I think most lawsuits come about because of a lack of clear communication,” says Scott Whonsetler, a medical malpractice attorney with the Louisville, Ky.-based law firm Whonsetler & Johnson PLLC. “The physician hasn’t communicated well with the patient, or there’s been a misunderstanding or unrealistic expectations because the two of them didn’t talk enough.” 

Whonsetler says that managing patient expectations and detailing a procedure’s risks are of particular importance. 


“Be open, be honest, explain all the risks up front before going into something like a surgery,” says Hertz. “Make sure the patient really understands what you’re saying and that what you said to them is documented.” And it doesn’t hurt to have a witness present. This person can sign off to attest that you laid out all of the risks to the patient beforehand.

Possible risks and adverse outcomes should also be clarified for patients’ families. Imagine your father is in surgery. You’re waiting for hours, and no one gives you an update. You’re worried, upset, and, in the absence of any information, you start conjuring up worst-case scenarios. Hertz says he was in such a situation. He assumed his father’s surgeon was busy performing the procedure, but he says he would have been greatly relieved if a staff member had at least spoken to him from time to time to keep him informed. “I can imagine that people in that situation would then want to blame the doctor if, in the end, there is a bad outcome,” he says. 

Better-trained staff could have remedied that situation, just as well-trained staff can set a positive tone for routine office visits, says Waldene K. Drake, vice president of risk management and patient safety for the Los Angeles-based medical liability company, Cooperative of American Physicians. 

“The staff interacts more with the patient than anyone else, and they are the least-trained people in medicine,” says Drake. “It’s imperative that the physician spend time training them.” 

That applies not only to office processes, but also to general courtesy. If staff members aren’t pleasant to patients when they arrive at your office, a negative pall is already cast over their visit before they even see a physician - and that doesn’t bode well if there’s a bad outcome, says Drake. 

Of course, if physicians themselves don’t respect their patients, that only compounds the risk. 

“I’ve had situations where, after the trial is over, the plaintiff said to me, ‘If your client had been a nicer person, this would not have happened,’” says Monty Warren, a trial attorney and a founding member of the law firm Coel and Warren PL in Boca Raton, Fla. “Often a doctor will get sued for a bad outcome because he didn’t express the right amount of concern or show the patient enough attention.” 

Drake adds that how physicians communicate bad results to patients is crucial. If things go awry with a procedure or an encounter, it’s best to be upfront and handle it right away. 

“We tend to be afraid of people who are complaining,” says Drake. “But if you just step up and say, ‘We’re so sorry. What can we do to fix this?’ a lot of trouble can be derailed.” 

As someone who’s been there, Veltman agrees. After the conclusion of his lawsuit, he went on to chair the American College of Obstetricians and Gynecologists’ professional liability committee. Today he is a risk-management consultant. If you’re not sure how to communicate negative test results, or if your attempts only result in further inflaming the situation, Veltman advises seeking help. Talk to your legal advisers at your affiliated hospital, or call your malpractice insurance carrier, both of which should be able to offer detailed counsel. 

The upshot is that sustaining positive communication throughout patient encounters and maintaining unwavering courtesy while addressing patient concerns can go a long way toward keeping lawsuits at bay. 

“It’s just human nature,” Veltman explains. “It’s a lot harder to sue someone when you’ve bonded with them.” 

Veltman says the second cornerstone of robust risk management is maintaining complete documentation of patient encounters. Note everything that occurs during each patient visit, including your detection of symptoms or the lack thereof, your diagnosis and how you arrived at it, the course of action you suggest to the patient and your rationale for it, details of the risks and benefits of the treatment options you discussed with the patient, the patient’s response to your assessment, and - if necessary - proof of the patient’s informed consent to any procedures you’ve proposed. 


This should become part of the patient’s medical record, which, if a lawsuit is later filed, will be closely scrutinized, first by a medical expert who will determine if there are grounds for a case, then by attorneys, and ultimately by a jury. Physicians who fail to dot all their i’s and cross all their t’s in individual patient records can leave themselves 
vulnerable. 

“Three-fourths of the lawsuits I get are affected either positively or negatively by how things were documented,” affirms Whonsetler. 

Dayton, who says he’s been through the “medical malpractice grinder,” is currently waiting for the fifth lawsuit to be filed against him to go to trial. He says that based on his experience, Whonsetler is right. “Disputes are lost all the time over lack of documentation in the medical record,” Dayton says. “I have become obsessed with the documentation.” 

Dayton and his physician partners invested $250,000 in an EMR system to help them achieve what they hope to be flawless documentation. Now, Dayton says, when he’s with each patient, he spends an extra four to five minutes checking off items on what he likens to a pilot’s checklist, asking each patient the same series of questions. “Do you have bleeding?” “Do you have discharge?” etc. He says the process is tedious and sometimes redundant, but it gives him needed protection. 

“It pins the patient down to respond to each question and provides a document trail of what was asked,” Dayton explains. So if a patient later argues that she told Dayton during a visit that she was bleeding and he didn’t address it, he can now produce proof to the contrary. The situation can’t devolve into a “he-said-she-said” lawsuit. 

Don’t have $250,000 for a fancy EMR? Don’t worry; experts say that although EMRs help make patient documentation more seamless and watertight, it’s also possible to achieve the same effect the old-fashioned way - writing it down or recording dictation for later transcription. But remember that years may pass before you’re asked to produce a specific patient record for a lawsuit. At that point, you may not even recall the 

, much less the details of your consultation. So regardless of method, make sure you keep all details of all patient visits at hand and organized. 

Of particular importance when documenting patient encounters is the physician’s rationale in determining the diagnosis and suggesting treatment options. 

After his brush with malpractice litigation, Russell became a medical expert in such lawsuits. He now examines potential medical malpractice cases and advises attorneys and plaintiffs on whether or not their cases have merit. “What you’re looking for is the doctor’s thought process,” he explains. “You want to see: How did this doctor end up making that diagnosis? What was he thinking? Often that is not in the documentation.” 

Russell adds that when a patient is noncompliant, the physician must take special care to document the situation. For example, Russell says that if one of his patients refuses care or refuses to go to the ER when Russell advises that he do so, Russell requires that patient to sign a statement acknowledging his refusal. Russell files these signed statements in his patients’ charts. 

Is such added documentation truly necessary? It isn’t legally required. But Russell says it would go a long way toward showing attorneys and a jury that he made an extra effort to emphasize the importance of treating a patient who, in his professional opinion, needed immediate medical attention. If, for instance, a patient later suffered a heart attack after refusing a trip to the ER, he’d have a hard time making a case against Russell. 

The added upside to this is that about half of his patients, when handed “refusal of care” documentation to sign, will grasp the gravity of the situation and agree to accept treatment or go to the ER. 

The scenario is all too common: A physician does a Pap test on a patient, and the results - which indicate a problem - get lost in the shuffle. Or a physician orders a mammogram, the patient has the procedure, and a radiologist detects a mass - but the results never make it into the patient’s file, and the patient never receives a call that would have allowed her to enter early treatment. Or a doctor examines the results of a prenatal ultrasound performed earlier by a technician and detects a birth defect - but the mother is never notified. 

“There are lots and lots of cases like that, where things fall through the cracks,” says Hertz. “This is one of the biggest malpractice risks: failure to diagnose.” 

The simple remedy? Organization. The best way to achieve it? Computers. 


“We need to embrace and leverage technology to assist us with this,” says Hertz, adding that pricey EMRs have tracking capabilities that can keep lab reports from ending up lost or misplaced. Staff members are alerted to lab results via a visual signal on their computer screen. That signal won’t go away until the staffer calls the patient with her results. Is such capability confined to EMRs? No, says Hertz. Lower-cost software can do essentially the same thing.

Drake says that handling lab results is such a sensitive, vulnerable area that she has nine full-time risk managers who regularly visit her company’s 9,200 physician clients to ensure their lab report systems are airtight. 

Drake’s risk managers advise practices to do away with the all-too-common practice of telling patients, “If you don’t hear from us, that means your results are negative and everything’s fine.” Drake says practices can never be completely sure that this is the case; positive results could be stuck in the wrong file. 

Following up with chronic care patients who require regular testing presents another challenge. 

Drake suggests that physicians or their administrators take the time to teach staff how to identify such patients and then enter their names into computer systems that can generate mailings when patients are due for testing. Or staff can instruct the systems to generate monthly lists of such patients, whom they can then call. Even a manual log or accordion file can serve this purpose, says Drake, provided dedicated staff keep careful track of the system.

Drake says another common process prone to mismanagement is phone logs. Staff must document calls to patients to follow up on lab reports or anything else, she emphasizes. 

Ever wish you had a can of lawsuit repellant? Well, now you do. Follow our easier-than-you-think advice to reduce your chances of ever being sued for malpractice.