It will help those groups large enough to have the financial crunchers and finance gurus go through the numbers, but for an individual or small group with limited time to do this process on his own - unlikely. It will require more time spent as a business man and less in practice - not a good way to keep earning, and can't trust this to the office help. the idea is great but how does this translate into something useful when the government and insurance companies will soon be more dictatorial in their rationing and re-imbursements - knowing just how much you are being screwed does not make it any more palatable. I guess that it is better for me to just not know how screwed I am.
I believe that these technologies can improve documentation that justifies higher billing codes while at the same time inviting audits for upcoding. With my EMR, I could justify a 99215 for a simple runny nose visit, but I could never charge that. Computers just cannot appreciate the complexity of a visit, which is the weakness of these systems.
The biggest problem with technology is there is quite an investment of time, money and training, and in medicine we are paid 25% less the last ten years. This has hamstrung every smaller practice's ability to make these transitions, and forced a move to larger practices. This is a fundamental shift.
Although our practice is an exception and has some very techno-savvy docs and practitioners, we have despite a large investment in EMR, disease management, and IT seen only increases in costs without profits, largely due to ongoing declines in reimbursements against inflation and other costs (including health care).
The resistance to a shift for paying for work when the patient is not in the office is the problem. We can do 50% of care without them in the office, but can't get paid for it. The biology of the human mind is also a factor because even if it will save them money and time, people are averse to paying $50-$100 and avoid an office visit.
The EMR has helped in the hospital mainly with PACS making time to review imaging properly more streamlined, but this has easily been offset by decreased inpatient reimbursement and the need to maintain a steady office practice or suffer losses from failure to use the resources in the office while at the hospital.
Billing technology per se does not help. We can send all the clean claims we want but continue to be either underpaid, or face ridiculous denials and delays, which appear to be organized crime on the behalf of payors. Our billing overhead continues to run over 15%.
I have watched the average specialist in my area either (A) go out of business and be bought out be a larger entity (75%) or drop staff and refuse to deal with complex problems (15%), leaving only a tiny minority like us to deal with complex care. The truth is that now you are paid more to shake someone's hand and do nothing, or do a well reimbursed procedure of marginal benefit, and say "hasta la vista."
I predicted the Medicare system would self-destruct last year, since the average MD lost money in 2008 and 2009, and now we are looking at no serious action to be taken with most even though they will lose more this year. I am amazed at the lack of action.
I'll add what I have said over and over again here. The current EMR systems have the ability to provide physicians with a smoother billing/coding stream. But the basic skeleton of these systems, based on the AMA's CPT codes, is flawed as Lee suggests above. What we truly do clinically is not necessarily reflected in the coding, the coding turns into a game, and the game is for physicians to extract as much cash as possible from the current third party system.
The goal should really be to streamline our ability to spend time with patients, document what is actually done for them at the visit and then bill appropriately for the time and effort of the physician.
The model that lends itself, in the purest form, to this transaction is cash. The cash, in the outpatient setting, could come from a credit card, HSA, checkbook or wallet...it doesn't matter. Then you could throw the current EMR system into the dumpster where it belongs.
When an intuitive EMR system is finally developed, that helps physicians practice, like your iPhone just works, doctors will not have to be forced to buy it or use it. That should be the goal.
Do you want to start a "Business for Physicians" program for residents? It will be a 1-2 week course educating them about what they need to know about business side. Conducted at various locations by rotation. ... or on internet by webinars. I will be glad to devote some time preparing the syllabus/material/presentation.
There is no question that teaching new physicians about the business of medicine would be valuable. But, shouldn't a primary goal be to simplify this business for the physician and the patient?
The intrusion of third parties into the physician-patient relationship has become a crushing burden as Sermo Doc 5 mentions above.
As a profession we have seen all sorts of industries develop to help us deal with the third party payment system to "optimize" our reimbursement.
I would submit that the third party payment system IS the problem. It is the problem that the health reform bills fail to address, or for that matter even understand.
So, how do you think the current group of students/residents will feel about having to take this mini-MBA course to figure out how to survive in the lethal business atmosphere that has been created around us for the past 45 years? If they correctly decided to not participate and follow another path...who could blame them?
We need to change this completely, not just accept it and figure out "work-arounds".
Unfortunately I think these tools which should make us more efficient will be used to control us - report, compare, limit, prevent our ability to care for our patients one on one as individuals partners in contract.
But they do offer the opportunity to free ourselves from the present system . . .
It may help some practices, somewhat, but the real problem lies with the overall position of medicine in our economy and the pressures brought to bear on medicine by the government, lawyers, insurers etc. It is like being in a vice that is progressively tightening. We have no current organization that speaks to our needs, and we are unable to collectively voice our concerns and be listened to by the public and others who might want to help. One day, when the public suddenly finds that medical care in the U.S. has deteriorated to a dangerous level, there will be a wake up call. Thank goodness for Sermo which is trying to help.
I agree with Sermo Doc 3. Primary care is pretty sad these days and looks to be dismal in the coming years....To be profitable, I should have gotten a MBA or wrote a book or something other than the profession I chose.
Something is definitely wrong. The fellow who puts bolds on a car in Detroit production line makes $84/hr. As a teacher in a medical school, I can attest to the fact that we no longer are getting the same quality of applicants as we did even ten years ago. If we go to a free trade system, it may benefit us but I am not sure all will be able to access medical care.
Jegee
I think getting paid by a combination of methods will be the solution.
Charge for our time like the lawyers do. So paperwork and phone conversations become billable, and we get reimbursed for the "cognitive" part of the work.
Charge for procedures like we do now, for the procedural part of the work.
Trying to bundle the two together does not work in the real world.
Also we need to fight for the cognitive turf. Allowing every Dick and Harry to bill for 'cognitive medical work" will bankrupt the system. Only properly credentialed board certified physicians should be able to bill for this. Counselors, nurses, homeopaths, naturopaths, nutritionists, etc. etc. will quickly bankrupt the system IMHO. Those mid level practitioners should only be able to bill with the signature of the attending physician for approval. JMHO
EMR is garbage medical record. It promotes bogus documentation by way of "defaults" and "templates", it promotes fraudulent "coding" practices, it is unclear in its ability to truly record and transfer the details of the exam / encounter / history / etc...... It is a huge waste of financial resources and it demands excessive ongoing financial resources to keep it alive and well, so to speak.
It is not in place for the patient, but for the "business of medicine"....which I guess is your topic here.
I just had a distal biceps rupture, while helping in Haiti....and the bill thus far, for its 45 minute simple repair.....has just about converted me to a Democrat!!! Where these hospitals and specialists come to think they are so valuable is beyond me. Maybe the income of some specialists should be reduced....or at the very least, maybe there should be some real competition and real financial openness injected into our care system....so that there is a sense of accountability in billing. Something needs to change...
My family BCBS health insurance (I'm a solo rural FP) is now $1400 per month! For a $5000 deductible plan....no eye, no dental, no pharmacy. We barely ever use it. Do the math. This is outrageous....and there's no stabilization in sight.
Physicians need to consider themselves as not only part of the fix....but as part of the problem as well. We are not free of involvement or causal relationship. It's not solely everyone else's fault.
We spend most of our time taking care of patients and how we can do it better.
Insurance companies and the government spends its time trying to figure out how to pay us less and demand more (like EHR). They are protected and immune to anti-trust and can collude at will. We can't.
Business school or not.... Who do you think is going to win ?
I'll confess, I am pretty intrigued by how the conversation is playing out (already!), not to mention the poll results. The PSI data that we'll be releasing with Athena shows that physicians actually have remarkably optimistic views around EMR/EHR (I was actually shocked). The real "nugget" was how little the physicians think the technology could do to impact their financial prospects. My sense is that is where conventional EMR has really missed the boat. As physicians were are trained and passionate about treating patients, not chasing down bills. It is a perfect opportunity for technology to do what we cannot do ourselves.
My group bills for itself and we are Athena customers of a year. The information we get from them has been extremely helpful. If you contact me privately, I'll be happy to share specifics.
The problem is our multiple insurance companies. The experience of many countries shows that one can have independent medical providers even with a national health insurance scheme. Even Britain with a national health service still has relatively independent medical providers. Our fear of socialism is what has allowed us to be backed into a corner.
1) Have had an emr since 2004. saved some money, cost more in other areas. EMR's are not a slam dunk, except for software companies and other businesses that thrive on making the doctor-patient healthcare interaction more cumbersome.
2) So at present we have the following situation.
doctor--> third party--> patient
You are proposing:
doctor--> Athena--> third party--> patient.
I have a better solution
doctor ---> patient
followed by ,
patient----insurance.
Get the third parties out of the doctor-patient interaction altogether.
I think it does help to see how much you produce, what are the charges and the reimbursements so that you can tailor your practice better to get better reimbursements. I do get a report monthly from athena and I like the feedback for myself and for the group itself.
Dan, this is a perfect opportunity for the Steve Jobs of medicine to step up to the plate and design an EMR that is functional clinically for physicians and works as easily as buying a book from Amazon.
My wife's cousin designs software for Apple. We have had extensive converstions about this topic. His conclusion...the current federal government mandates and the current coding system are roadblocks to the development of a physician friendly EMR.
When it gets to the point that a check-up for my car or a single simple perscription cost more than a doctor visit its time to quit. Oh lordy that time has already arrived.
EMR: great, if it can make billing more efficient, simple, and accurate. Must require less time not more. However, when it comes to the nuances of diagnosis and management it fails completely.
If we keep on barking ONLY about our income, the patient's, insurer's and regulator's perception of doctors as a bunch of money obssesed opportunistst will rightly solidify. How about doing some work on quality of care or refusing to follow the "patients last" ethics so common today?. That's what is killing Medicine!
I would also agree that you can't make critical business decisions in any practice without understanding your payer mix, why you bill what you bill, how much each payer pays for the codes you bill and what their clean claim turn-around time is.
You must have this monthly and meet with your practice group to go over these with a fine tooth comb. You must review each and every rejection as many are bogus. The insurance companies goal is to take your patient's premium money and keep it. The more excuses they can find to hold onto it, the better for them.
This is a battle in every practice...sad, but true. None of us should be afraid to fight for what we deserve for the services that we provide.
For EMR to be truly successful, all the offices, clinics, labs, x-rays, hospitals etc have to be able to communicate with each other which means some standards are going to be needed.
If a doctor can find out what other doctors have done in their offices/clinics, the results of all labs and x-rays and hospital admissions, then it can be helpful, save time in tracking things down, save costs by not repeating things and improve quality as patients do not always remember or tell the "whole truth" about their history.
Throw in pharmacies so can see if the daily medicine prescribed is being filled as needed, doctor shopping and drug seekers and it becomes even more valuable.
Something is going to be needed with the initial costs and upkeep .... though may be able to save employee time, and overhead, by being easier to get more information about the patient.
Also, if have access when at home and on-call can help with that too.
The problem with this type of access, is security from hackers looking for this information.
i agree that we need to go back to Patient Responsiblity where it is possible..obviously there are those patients who even with nat health services do NOT get adequate care.
the ideal is stil patent pays doc and then works out with insurance co.. and the best was always that patient HAD to PAY a PERCENT of bill.. therefore they discussed and decided and helped controll costs.. ie they actually might really work at PT before expensive tests.. after my own shoulder surgery i watched the dynamics in a PT dept of hospital.. even those OFF work for short term disability DID NOT FIND TIME TO DO PT to help themselves... why ?:? NO FINANCIAL repercussions! they did not appreciate the expensive care they got for minimal invest..
My Kid recently has been around to diff med schools and training programs in Sr year.. HUGE inefficiencies where there is NO Electronic medical records.. constant battle to get results. and slower... having said that,, i think the electronic advantages are being used AGAINST US.. when the system gets too complicated it is used to PAY US LESS rather than care about our care of patients being more efficient..
Physician income is not at all part of our health care problem. Our income makes up less than 15% of every dollar spent. Stop bitching about the fact you did not choose a higher paying specialty. I made my choice and its no ones fault. Should an office based doctor with no hospital call, weekends, holidays make anything near a specialist who does all that and works 60 hrs/wk not counting call? Hell no! But, if a dermatologist or opthamologist makes much more than me with half the work should I expect them to make less. Again, hell no. If I wanted to be an optho I had the choice. Lets not bicker. The waste and excess is in the tests we order, drugs, hospitals, dme, hospital/office equipment, malpractice, etc. Lets focus on that.. If we can not stick together we will continue to get screwed. Hospitals, payors, politicians all know that we are all independant(of each other), competitive (with each other), preoccupied with our work, and thus EASY TARGETS.
btw my kid comes from a Med school with latest EMRs so it is also frustrating to go to places where norm is scattered records.. slowly making way to chart... they do use different templates so they do not have to put in so much garbage in reports of asking for greatgrandmothers fathers history in middle of acute life threatening emergency.. but i have seen tons of extra garbage put into emr s that i seriously doubt was asked or done ..
The problem is the very essence of a corrupt third party payor system that has formed a toxic alliance with the government. As long as insurance delays payments, and plays their games, and bases their rates on medicare and not what it takes to provide medical care, then we are all up a creek (you know which one) without a paddle. There is nothing fundamentally beneficial with athenahealth, it can't make payors pay well or on time, and I believe the insurance companies will STILL find ways to lower payments, raise cost, and collude amongst themselves (which is what Medicare does--allows an acceptable form of collusion) to provide less care at a higher cost.
While I am glad that EMR/EHR exists to assist in documentation. The fact of the matter is the pay rate, free work (paperwork, prior auth, refills) and increasing business overhead are forcing us physician out of business. If your overhead is $250/hr and you saw a patient every 15 minutes while receiving around $65 per patient, you supposedly profited $10/hr. However, you the physician is still there at the end of the day, after most of your overhead (staff) went home, perusing over labs and completing FMLA, worker's comp, disable parking pass, motorized scooter paperwork for free (part of the global package as the insurance industry stated).
The third party system is dying and is being met by angry physicians drowning in various financial situations. Athenanet is a good idea but the third party system has to be phased out into something that patients deal directly with. We can not continue to deliver what our patients demand of us which is high quality care. We know that there are costs, but if the patient is able to deal directly with the third party payor then this will free up time and will allow everyone to coexist.
Technology is great but expensive to research, develop, implement, and market. All these costs are added to the cost of Medical Practice. We cannot continue down this path forwever without there being cost cutting elsewhere.
So, what's the answer...elimininate Medicare/Medicaid, privatize Soc. Security, death panels, rationing of HC, no care for illegals, age 80 for Medicare eligibility, Tort reform, Insurance Reform, more MD cuts, stop STIMULUS/TARP/CLUNKER spending, more expensive EMRS, HSA's, permanent lower debt ceiling, 70% tax rate across the Board, or Revolution, etc.???
Take your pick (s), we can't have it all and survive. We can't have it all.
I am a primary care physican and am lucky to have been privey to two great computer medical record systems, EPIC and Partners. I must admit they are both a life saver. They do make our work easier in terms of documentation and looking through the chart, sending of letters and communicating with the pharmacies, patient setc.
The system I am in right now, is shared by 4 to 5 major city hospitals and so I am able to read specialist notes from cross town, or look up any lab admission etc
It is much better than waiting for the typed consultation letter, instant, typed radiologist results instant. I can send of letters to patient while I am at home and know when patients open then up and read them!
I like the fact that patients can look at their own labs them selves.
I am all for electronic medical records and I think they make our work easier if designed properly.
We shouldnt be fighting against this, we shold be fighting for tort reform and the fact the insurance companies dictate to us, when to screen and how to screen otherwise we get dinged without giving the patient any insentive or responsibility to make sure their BMI's are normal, their BP's are under control etc.
We have been put in the middle between the pateints and the payer and that is what we should focus on as physicians and that is what is killing us as a profession!
I am one year into my offices EHR. I am the practice manager and I also see patients daily. The best part of it concerns being able to read my 9 associates evaluations. The worst is the time it takes to customise a template and have 9 associates not use it the same or accidently forget to change the predetermined template findings to the opposites (all okays into this finding was not normal). It is very easy to make this error. The system cost approximately 190K for software and hardware. The upgrade we are adding will cost another 60K so we are totally integrated with the practice management system provided by the vendor. We have archieved 36 years of patients onto RDVDs which can be retrieved and placed the last two years on the active status part of the system. Alot of work and alot of money. Do I think we will ever really get a full return on the investment-never/ever. Do I think my billing has improved-somewhat, but not to the amount I expected. Do all of us "swear" daily at the foibles of the system-yes. Will the government stimulus help me-NO...we don't have over 20% Medicaid population.
What do I think would improve the
Great discussion here. The problem is not EMR. It is more about how to cut the middle man. We provide services to our patients but must fight a third party to get paid for our services.
Where else in the economy do people eat at a restaurant but the restaurant owner has to fight the credit card company to get paid?
Did anyone recieve any business education in med school? I sure as hell didn't. Paid back my NHSC time and then too scared to go out on my own so became an HMO indentured servant. I have since left...
Having been in solo,private practice for over 30 years[graduated 1973-FP since then], I have seen the 'playing field' change over the years. In July of 2009, I went to the dark side and became a hospital employee in hopes of mentoring the future and eventually 'slowing down'. Our practice has been using Athena since then; we had another EMR prior to that. I would definitely states that Athena is a superior product that is definitely aimed at the financial side more than the clinical--seem these folks/geeks still need better interaction with us grunts in the primary care workforce. As practitioners, we need a better understanding of the $ end, but on the other hand from what I have seen, the EMR designers need a better understanding of the daily work flow
'As physicians, the loss of control of our financial fate is inseparable from the gradual demise of our profession.'
I disagree. This statement isolates physicians' financial fate from that of the rest of the health care system, the patients and the country. This is a poor way to look for solutions to our problems, which are inextricably linked to others'. It also isolates us politically, when we need more allies than ever. And, while a certain degree of financial security is necessary, and should be obtainable in a way that leaves docs a little time to actually see patients, it is not equivalent to our profession's survival or demise.
As long as the monopoly of health insurance companies goes unchecked and doctors are in restraint of trade when negotiating in numbers both the patient and physician will continue to suffer.
It is unbelievable to me that the government wants to demand that all medical offices institute electronic medical records , when no studies have shown universal, efficacy, benefit or cost savings. Indeed it will leave medical groups significantly in the red, lead to mechanical assessment of the patient and leave medical records open to unwarranted snooping by non medical entities for less than noble reasons. There are some suggestions that at the large clinics (Cleveland, Mayo) dealing with tens of thousands of out patients they have achieved some cost savings. The problem is that their cost savings are probably not applicable to small groups or local hospitals.
It reminds me of g.i. endoscopy 30 years ago. When we were just looking at the stomach no reduction in patient mortality occurred . When electrocautery was introduced and ulcer bleeding could be stopped mortality and morbidity plummeted. The analogy is clear,when you simply document something it does not get rid of the problem nor should one expect an improvement in morbidity or mortality of any significance. Moreover do these potential vast expenditures by the medical community give enough bang for the buck?
On the practical side of electronic billing the best thing I did in my practice was having a professional billing company do all the billing. This got rid of of constant billing employee retraining ,sloppiness and non followup of refused procedures and equipment updates. For four or five% of gross billing I got rid of a lot of headaches.
It's interesting that Dr Palestrant threw EMRs, EHRs and billing systems into the same mix. They are fundamentally different beasts.
EMR and EHR are similar terms pertaining to different scales as they are used now. The EMR is the medical record, in electronic form, for one patient while the EHR is the aggregate form of that record. These are not hard and fast definitions, but they do seem to be the evolutionary direction in which the industry is headed. Both terms, though, at least theoretically relate to systems intended to capture information about a patient's state of health and the medical interventions used to optimize that state.
Billing systems, on the other hand, can be but are not necessarily related to health records and, in my opinion, should not be. Billing systems have the potential to increase the efficiency of practice finances, but they cannot improve them per se except to the extent that, within the current third party payor system, they can allow upcoding. This can only occur within the context of integrating billing into the EMR, and this approach will always be a money loser for the individual physician or small practice.
The insurers have the willingness and the resources to change billing criteria at their whim, and the individual physician cannot afford to re-jigger his or her billing system and EMR simultaneously each time the insurer does so. Yet this is what would be required for a billing system to offer improved finances to the practice. The current uproar over CMS's Meaningful Use criteria offers a perfect example of this. CMS is dangling a carrot - up to $44k per "eligible physician" - to physicians in order to get them to "upgrade" to EMRs, but the requirements for meeting the necessary criteria are not yet well defined, and there is considerable and contentious debate in the IT community over what rules should be defined and at what time. And integrated billing is an assumed but completely separate (and undefined) part of that equation.
The bottom line is that the regulatory environment has become so complex that medical billing is beginning to collapse under their weight. Making a substantial investment in the technologies necessary to join the game is a huge financial risk, at best, taken for little gain (a reduction in the costs necessary to join is the best possible outcome...) Once the investment is made, the ongoing costs will, beyond any doubt, exceed the initial investment, but with no additional gain. And after that investment is made, the physician is essentially "locked in", with no chance to exit other than to scrap the entire system at once and alter the basic economic format of the practice. There exists the possibility of the avoidance of future, as yet undefined, payment reductions, but only if all the as yet undefined criteria are met within the as yet undefined deadlines, and with both the criteria and deadlines variable according to both the political desires of CMS and the economic desires of the insurers, there is almost no chance for a meaningful long term improvement in practice finances.
If health care was a free market, then billing efficiencies could be expected to translate into increased profits. With the price controls imposed by CMS, however, and given the current and potential complexities of attempting to implement billing systems, the costs of doing so almost certainly cannot be recouped. Any increase in billing costs will translate to reduced practice profits.
The only sensible course is to eliminate insurance contracting from the equation and, once the practice has re-stabilized, begin at that point to take steps to reduce billing costs (and only billing costs, unrelated to the EMR) as far as possible. At the same time, steps could be taken at that point to implement EMR strategies which can reduce practice overhead and improve patient care by reducing record storage costs, increasing the speed and geographic locations at which records are available, and maintaining clear, concise summaries of historical patient interactions.
The ultimate promise of the EMR is secure, rapid, widespread availability of patient care data. GE's TV commercials during the Olympics have illustrated that point very clearly. By using the EMR primarily as a tool for gathering billing data, however, the current third party payment system has suborned that notion to the extent that it becomes economically non-viable for small practices. It remains to be seen whether that lack of viability will also be the case in large systems.
My practice has an excellent EMR as far as EMR goes. It integrates well into the billing side and does help establish level of service. However, EMR is time consuming & very expensive. EMR has the potential to be used against doctors with regards to tracking performance, not getting recommended testing, doing extra testing, etc.. There is a large expense to ongoing maintenance fees, software and hardware fees, user fees, etc. For our practice of 5 Peds the maintenance is close to $20,000 per year. This does not include any hardware replacements, such as lap top batteries ( $110 each). There are system "slowdowns, freezes, etc.. These all slow productivity. It is not all bad, I can examine charts from home. I still prefer a Paper chart by far. The sales pitches are all about the ROI and how much more you can bill and how quick you can payback you investment. In reality it is just one big ongoing expense.
No time to read all the responses due to patient care obligations right now, and a pile of charts . . .
BUT HERE IS WHAT I NEED -
For a simple low risk visit, my handwritten scrawl of "Sinusitis - Ceftin 500 bid x 10d" should suffice. I shouldn't have to document at what age the guy's grandfather died of a stroke to get paid my level 3!!!!!!
ONE OF THE MAJOR THINGS KILLING THE PHYSICIANS IS THE OVERHEAD. We are the draft horse in the traces hauling the cart with an ever-increasing cadre of administrators and transcriptionists and coders and auditors to meet a mind-boggling array of ever-increasing regulatory hassles.
We need to stop playing that game.
They want to enforce a system-wide EMR to audit us and pay us less - not because it'll help us or the patients.
When I was in med school, our chapter of AMSA (American Medical Student Association) ran a regional conference on business side of medicine. It was 1985 and we were just at the beginnning of the alphabet soup of HMO, PPO, etc. We had some enlightening speakers. But again, this was run OUTSIDE of the general curriculum. It is a shame that the business side is so overwhelming and sours us all on what should be well-liked career.
I personally would like to have a online system that helps all physicians in private practice claim their stake in the game. Our expertise in invaluable, we save lives. We work so hard for so little. We are losing the game quickly, and we must act swiftly. A online system that creates a free enterprise and open markets in healthcare. How? Well one physician will not cancel a contract because his neighbor will benefit. What if we had the ability enroll physicians within communities, and had a power of attorney to cancel insurance contracts when 95% of the physicians have approved cancellation of a particular contract. That would free those physicians to be "out of network" and request payment in full. The insurance carriers should not be making decision on how much we are getting paid, this in an unprecedented occurance. Our freedom is vital to our happiness as physicians.
Answer to question:Definitely not.On the contrary,it will further enslave the indentured servants,also known as physicians.I only speak for my primary care practice.
I have run an electronic practice since I first went into practice 21 years ago. I used the knowledge gained to create my own IT firm, which I have run successfully during the same time period. I also built and ran a multispecialty surgery center, which imploded when insurance reimbursement was cut by 75% by local insurers to match MC rates. Based on my experience I can categorically state that the answer does not lie in EMR's, billing software or added consultant expenses. The core problem remains insurers' predatory practices with regards to delayed reimbursement, discounted fees, use of proprietary self serving databases to misinform patients and exploit physicians and our government's collusion in the entire process. No amount of business know how or efficient practices can overcome such a rigged system. Unlike the dinosaus of the Cretaceous, we have seen this "comet" coming for quite some time. Unless we revolt as a profession, stop insurance participation and force our politicians to hear our plight, the private medical practitioner in these United States of America is about to join those dinosaurs.
better documentation and increased support for 99215 ... Oh, we've stopped paying for that, we now pay the same as a 99214
Oh, we stopped paying consult codes, we now just pay normal office visit codes.
Sermo Doc 38 has it exactly right - a quick note that contains appropriate info is what is needed, not a 10 page EMR note noting every little bit of family history and ROS which in reality were not done. i'm telling you the next big wave of lawsuits is going to be over little notes in EMR that are damming and not followed up on.
The answer is not to find better ways of jumping through their hoops, the answer is to stop jumping at all.
Be a cat who looks at them like "you're stupid if you think I'm jumping through there" rather than a dumb dog happy for a little doggie treat at the end of the day.
1] EMR and billing processes, although ideally linked via software, are distinct management issues
2] athenanet lets you know just what third party payers are doing to screw you
3] E+M codes, even on paper, are the #1 time waster for MDs
4] better to have no intermediary between patient and doctor - medical debit cards - third party payer reimburses patient - then you do not need snoopware as you are not getting screwed - document only what is needed to provide the care to the patient - three visits on one piece of paper remember those days?
Agree fully with Sermo Doc 43. Don't put glitter and tinsel on the hoop.
I also agree with Sermo Doc 19 that what you are proposing is introducing more administrative complexity into a process which should be simplified. Eliminate the third parties, don't let them proliferate.
If as a group doctors listen to Sermo Doc 19..things will fall in place! We are like miswired marionettes willing to dance to the tunes of every bum administrator and politician. In my practice I write very few prescriptions, discard any fax from companies like MEDCO, toss out any medrep who wastes my time and work with most insurance companies on my terms...which means no calling anyone, no pre-authorization, if PBMs want to change meds feel free but take responsibility( we fax them back such letters) . We keep credit card of patient on file or ask them to pay cash to be refunded later if there is any equivocal payment issues. I love to take care of patients but I hate the bum work. We have really satisfied patients. Each one of us needs to strive to develop patient-centric practices. In this equation EMR and billing services have a role but a minor one. I doubt even Athena can save a practice if the practice is already on fire!
the politicians are Wrongfullly focused that there will be cost savings with electronic records expansion... WISH it were true..in FACT Docs will be more harried and paid less.. SIMPLIFICATION IS MOST NEEDED TO COST contain for quality.. not expansion of " counting each dot in the sentence"
as i said before.. Before Medicare ran out of money in 1990 by its OWN FAULT and then started PRICE FIXING DOCS, we had easier systems.. that did not require so much extra documentation..
Polticians claim there is so much FRAUD and they must believe that they can find it by excessive coding and charting requirements.. IN FACT , for the majority of HONEST DOCS who are just trying to TAKE care of Patients and earn an honest living,, this will be USED against them that they did NO CROSS their Ts and DOT their I (eye)s.
they obvioulsy were able to investigate the rare fraud when the codes were simple..
SO, the expansion to Insane documentation and Detail is ONLY to make a game to DENY payment.
SADLY ... that is why when the patient has to contribute to each service ( 20 - 30 % copay) , the PATIENT WILL ASSIST in making SURE the charges are correct and also try to keep lower
Doctor-patient relationship. In the fantasy land of tort reform, the short notes would suffice.....I think we need to get wise and eliminate the middlemen payers. Let the patients deal with them....
Sermo Doc 14 's thread (Family Medicine Posted Feb 24, 2010 at 11:04 AM ) is onto something, i.e. billing for MD's time expended on researching, documenting & communicating their findings as do attorneys for their 'due diligence' time. (Such an option was also suggested by a few other Sermoans in other columns.)
Given the adamantine & well-nigh invincible resistance of the Trial Lawyers & Consumer Lobbies to Tort Reform, then perhaps it is time to seek 'balance' by MDs proposing (demanding/litigating for) fee schedules similar to those of trial lawyers based upon 14th Amendment protections, filed by , say, a Big Insider Organization like the otherwise much-maligned AMA? Altho' I doubt that, in such a hypothetical scenario, MDs would ever see much (if any) additional $, it is possible that a useful debate regarding med-mal/tort reform nat'l agenda might emerge.
Remove anti-trust exemption that insurance companies have purchased from Congress. Remove exorbitant patent extensions that pharmaceutical companies have purchased from Congress. Remove unlimited medical care that Medicare recipients have purchased from Congress.
Is there a pattern here?
Will TERM LIMITS for everyone in Congress solve any of this?
I have not seen the system yet. But I do believe a well build EMR and medical database could be could for both patients and physicians. The problem is, neither of them exist!
I have an EMR. I do not think it changes the business aspect of my practice although using it there is a tendency to "upcode" because it is easy to document all the things you do with one click.
To me the answers are simple and havebeen stated: Remove third party from the equation and make the patient responsible.
Basing reimbursment on "documentation of a thorough ROS" is utter BS and is just a way for third parties to interefere wtith the true value of what physicians do.
Remove defensive medicine fromt he equation: Being forced to document every little thing for fear of being sued is a large part of most practices as is ordering unnecessary tests to "cover my ass".
I agree taht most physicians do not understand the business side of medicine, however although we are "small businesses" were are not in it for the business. All of us have compassion for our patients which comes first. Without that compassion the third party insurance fiasco and Medicare issues would not be issues because no business would have accepted those terms from another company.
When what we do is paid at a reasonable rate wihtout interference from outside sources or without fear of repercussions of litigation for a known risk of a procedure then we can all practice the great art of medicine again and everyone will be better off for it. When compassion, knowledge and experience are used patients will have better outcomes, at less cost and more peple will be able to be taken care of.
As far as EMR, a web based program that is linked to a smart card that each patient has on them and is inserted into a card reader at each office/hospital so that all old inforamtion can be read and all new inforamtion added to it is the answer...this is portable and secure because the information is only stored on the card. Also documentation should not be linked to reimbursement.
My local hospital is instituting an EMR that will allow us to share and exchange records and will subsidize most of it. They will also have seminars to teach it to us. What would be my incentive to join athena.? Also what is Sermo's incentive to partner with Athena? Is this the beginning of another conflict of interest ala the AMA?
The EMR only benifits the payors..ie third party insurers and the government. I predict the future will give them the ability to directly access our office notes etc, with the sole purpose of detecting fraud and ultimately limit reimbursement to us. (Big Brother!) Has anyone here ever tried to read a note generated by an EMR?...its generally a bunch of irrelevant garbage so we can all "upcode". I agree that the underlying problem is with the entire CPT system, especially E & M codes...we should go back to asystem where we are paid for our time and not for our level of documentation. We could then spend less time on documentation and less resources on billing third party payors and more time on our patients aand families.
Doctor SH is right. Letus deal with the patients and let the patients deal with the insurers. They are the ones who chose their carriers and they should be tthe ones dealing with it. We would all make less due to increased competition and transparency but i bet we would all be taking home more cash due to a decreased overhead and have a much better quality of life. After all, Athena would cease to exist if the insurers dissappeared so don't fall for this new alliance stuff. Take back your practices and refuse to jump through any more hoops. Together we can all save the system and ourselves.
Nothing will truly help until such time as physicians can and will actually get paid for the things we do and not have to "play games" in order to do the right thing by our patients. But we are all "rich" and, of course, will be subject to any and all of the "soak the rich" taxes that will be coming down the pike. What ever happened to the American ideal of "you get what you pay for"?? Very frustrating. In radiology, in order to "keep up", we now must interpret 30% more exams/yr than 5 years ago (and these exams, especially CT and MRI) now often have many hundreds of images, not the 40 or 50 of years ago). It is like being on a treadmill-you keep getting further and further behind and time constraints are such that you simply cannot give the time and effort to each case/patient that is warranted/necessary. (Of course, if a third of our practice wasn't reviewing "defensive medicine" imaging required to stave off the one-in-a-thousand instance of real pathology but which, if missed by the clinician, would result in a multimillion dollar lawsuit, the outcome of which is dependent upon which lawyer can sway a jury of lay people, not the realities of the care...)
Enough ranting-I leave with an interpretation of the three laws of thermodynamics:
1-Things are getting worse.
2-Things will continue to get worse before they get better.
3-Who says they will ever get better?
Absolutely agree with much said above, that the real problem lies with insurance. If I want a the pool man to fix my pool, I better be ready to pay him when he comes over. Same for plumber, electrician, my housekeeper, landscaper, whatever. I don't understand when people started thinking that paying 15-30$ to see me is too expensive. I remember having to pay 35-50$ co-pay in the 80's (if that's what it was even called then).
Anyway, I also want to say that I don't think many docs who choose to be employed think that is easier. I choose to stay employed because my husband has to move every couple of years for his job, so I have to stay mobile (it's actually a pain the booty). Also, don't think that those employers don't make us employees justify our salary. There is just as big of a push to be well versed in coding and compliance with a large corporation as there is with your own practice, and yes, it's irritating to see how much I make them and how little they pay me, but then again, malpractice is a little easier in this situation than on my own and there's no tail. And that's important when you move a lot. We all have the same things at stake here, employed or self-employed. I wish we could all find some common ground and stick up for ourselves over these issues.
EMR is great, good and bad about it but overall the potential for ease of integration is difficult unless one system prevails (ala Microsoft). Being able to reach accross the country for someone's records would be incredible, but the system itself would be massive, expensive to maintain and as always - typically down and non functional. The billing aspect is somewhat useful, but just another layer between unless there is a justifying reason, such as quicker turn around and no use by auditing firms or insurance agencies. Sorry, but I am basically a very paranoid individual over the past 15 years of my my much longer practice , and the currnent climate is not making it easier to trust anyone.
SHARING WHAT I JUST READ, COPIED, & PASTED WHILE READING MORE ON THE E.H.R. STIMULUS INFORMATION:
CCHIT will be sole health IT certifier, for now
By Mary Mosquera
Friday, August 14, 2009
The federal Health IT Policy Committee today endorsed recommendations that would leave the Certification Commission for Health IT in the short term as the sole organization authorized to certify health IT systems that qualified for funding under the economic stimulus plan. More certifying organizations would be added later.
Certification of electronic health record systems that met federal criteria for "meaningful use" of health IT could start as early as October, members of the Department of Health and Human Services' Health IT Policy Committee said at the August 14th meeting.
Under the plan, CCHIT would provide a preliminary stamp of approval that health IT systems were HHS-qualified or certified until a final meaningful use regulation is published at the end of the year, said Marc Probst, chief information office of Intermountain Healthcare and co-chairman of the Committee's certification work group.
Preliminary certification is meant to give providers and vendors enough certainty to proceed with planning, designing and purchasing systems in 2010. The HHS certification-qualification would mean that a provider purchasing the systems would be eligible for Medicare and Medicaid incentive payments under the stimulus law beginning in 2011.
Once meaningful use is finalized in December, national health IT coordinator Dr. David Blumenthal could determine how many additional certification groups could be set-up, Probst said. The national health IT coordinator's office would create a process to select other groups with assistance from the National Institute for Standards and Technology.
Blumenthal was positive about the proposal. "I think the workgroup has given us a very thoughtful and workable solution," he said. His office will review the transition plan.
In an Aug. 11 letter to the workgroup, CCHIT provided details tabout preliminary certification. Under the plan, CCHIT will certify some individual health IT components, such as electronic prescribing, for providers who do not have a comprehensive electronic health record system, it wrote. CCHIT would continue to certify comprehensive EHR systems as well.
A fair amount of meaningful use criteria is already part of existing certification requirements, Probst noted. "We now have all the details to put this preliminary plan in place," he told the Committee. It will be submitted (to the Office of the National Coordinator for Health IT) so starting in October we can start doing testing for HHS certification or qualification," Probst said.
Overall, certification should focus on meaningful use at a high level and leave the specifics to the healthcare provider, Probst said.
"We're not trying to say how the systems will work," he said. For example, the criteria require that providers' systems be capable of alerts for drug-drug interaction but not how the software should work. "We need to move into second gear beyond harmonizing standards," Probst said.
For electronic health record systems that were certified in 2008, vendors and providers would only have to update certification for criteria that is different with meaningful use, or gap criteria, such as a privacy review.
IN MY SIMPLE THINKING & ASKING, WHY CAN'T C.C.H.I.T. FORMAT THE E.H.R. FOR ALL PHYSICIANS, FOR UNIFORMITY & ECONOMIC REASONS?? As a dolo practitioner, I cannot really afford it and the government does not have to pay $44,000 per physician starting 2011 IF THEIR E.H.R. WILL BE CERTIFIED!!
Perhaps the Sanest and SIMPLEST is to FORCE THEM to HOURLY US.. then we can establish that this is unrealistic given our MANY MORE YEARS OF COSTLY EDUCATION than Lawyers.. but stil needs to be with patient with skin in the game.. because if they have to PAY too they will become better more effecient patients
Dan, I admire your intiative and creativity, but I think approaches such as Athenahealth are the wrong way to go. A fundamental cause of skyrocketing healthcare costs is the "consumer-payer disconnect" that results from doctors billing insurance companies, rather than patients. We'll never be free from the resulting excess costs and hassles; and there will never be normal free-market economics in healthcare, where practitioners compete on price and quality, until we completely dissociate ourselves from insurance companies. Patient should be dealing with insurance companies, not doctors, in my opinion.
Your for Better Healthcare,
Dan Jones, MD
www.JonesPlan.BlogSpot.com
Now that I have read most of the comments, I am with Doctor SH.
Why the F should I need spend hours everyday to learn and follow a CPT coding - billing - collection process that adds very little to the patient care????????????
We need to find ways to dismantle this system, not give it more power.
New model of practice: Pt comes. Pt pays. You provide care. You write a note that is more of a medical note than of a bean-counting gimmick. You go home. Period.
Praying can help but some are helpless.... Orlando doc
take for instance NY state is highest in nation in taxes and a major Brain and Economic drain is occuring with Rush Limbaugh and Golisono (Paychecks co ) the loudest... rest are doing quietly.
if you join up on the
www.onlinetaxrevolt.com
march to washington dc for april 15 by computer you will see major states trying to do something about this..
NY state and CALifornia are CLUELESS.. in NY state there are only TWO of us standing.. this entire period since started... Michael Regan part of this..
i am watchiing people regularly be taxed out of home and no one still seems to get upset .. and DO anything..
yes the 21% cut can do for DOCS what Large Increases in Cigarette tax does... get some to make progress... Unfortunately many of the new docs have no experience to understand what is going on as often they are salaried and have never seen the actual insane billing reimbursement or challenges.. THEY will , instead, experience JOB termination,, VERY SAD as the "employers" keep cutting costs ....
i am hoping they will wake up and help effect change that helps reimburse them properly for their cost of ed... Here too is a problem.. those whose parents did not earn much probably have no debt and could care less what their fellow classmates are going thru.. I do hope i am wrong here... but in college town here ,, very few kids actually know what their debt is and do NOT know if other classmates have any debt.. THEY DO NOT TALK about it.; some are embarrassed to talk about it too.
I know you don't believe in united front thru a type of physician union but if you get three physicians together they will have three different opinions and none will move. You need a strong leader who can defend the rights of the physicians. A strong leader is the only way it will work and a united front without it we will not have control over our future. We need "balls" E.J.Brotman M.D. I have said this before but no one has answered me
I am practicing medicine pretty much the same way I practiced a year ago. The only difference for me is that I am documenting my encounters using an emr. I have a certified coder who does the coding for me although we sometimes argue over what the code should be. We document time spent. I was just shown my billing stats and over the past year, the # of 99214 visits that I have done has nearly doubled. I am not doing anything different except using my emr. My records are up to date, accurate and my billable time seems to have increased without me having to work more hours because I can more efficiently do my work and document it.
Well, not surprisingly this has generated a fascinating conversation! I think there are at least three distinct issues here: 1. EMR/EHR (nobody has given me a convincing explanation on how they differ) 2. Billing (lots of vendors out there from mom and pop operations to pretty sophisticated) 3. Strength-In-Numbers (Athena calls this a rules engine, part of their AthenaCollector)
We are going to try and tease out all of these components in a series of grand rounds topics over the next few weeks. There are also some really unexpected findings from the PSI (Physician Sentiment Index) that Sermo & Athena will be releasing (turns out that physicians are MUCH more optimistic about EMRs than one might expect). My sense is that 1 & 2 tend to be confused quite a bit and they likely to have less opportunity to impact the financial health of a physician practice than 3 (rules engine).
I am with Sermo Doc 7; I am praying for a 21% pay cut. Only then will everyone just quit this s**** and bill patients directly. Screw all third party payers. Post your prices so patients can compete on price and quality. I am telling you, the portion of my practice which is cash money (not all cosmetic, a significant portion who want to avoid the hospital and have no insurance) is equally rewarding financially, even with a lower charge. All the overhead is cut out of it and no dealing with insurers.
This week I am working in a clinic with EMR. While they all have experience with it-
There is a complaint, an issue or a problem with EMR about once an hour.
It is like purgatory.
insurance free healthcare will be less expensive and financing a lower bill is easier than a higher bill. also when they see a lower bill, they will stop choking down our throats.
Lantus cash pay at Walmart $103 Charge to insurance at Walmart $160
45% cost saving just by letting free markets work!
In 1948 many pollsters had Dewey defeating Truman easily. Conducting polls by telephone was relatively new at that time. Republicans were three times more likely to own a phone than Democrats. This may not be the same phenomenon but the possibility should be considered.
Stop working for the Insurance companies. Liberation now > Without physician capitulation, there is no one to provide the service, hence no product for insurance companies to sell. Get a backbone and not a job
I am a little surprised by the tone of this letter. This is a prosfession we all signed up for. The financial rewards may decline over the next few years, but for me me at least that has very little influence on why I do what I do.
And have any of you talked to your friends with MBA's about how well their doing? I have two goof friends, MBA business types, both very bright, but the bottom has fallen out of their industries (one in tourism, one in high end sporting gear), and both of have lost their jobs with poor prospects.
People are not going to stop getting sick (nor, for that matter, making themselves sick), and our unique set of skills will ALWAYS be in demand. Stop feeling sorry for yoruselves and start remembering why it is you became a physician in the first place.
OK, I agree that 3rd party payors need to be scrapped. I agree that we will only be free when the patient pays us directly. Now, how do I go cash only when there is a competitor FP right across the street who has been here longer, has more patients, uses mid-levels, & he is not going to go all cash? I will simply lose most of my patients, unless I cut me fee down to what they already pay in co-Pays. I want to scrap those health insurers.....but (aside from already not taking new medicare, tricare, or ANY medicaid) how can I realistically do this?
The solution for primary care doctors, and all physicians, is:
1. Patient pays directly at time of service- cash, credit card, or money order. Patient provided with printout of information needed to file an insurance claim. (If EHR can do this for us, it may be a worthwhile investment.
2. Patient files for reimbusement with insurance company. If he needs more infor or help from doctor's office, this is an extra billable charge to the patient.
3. With third-party payers out of the loop, office staff can be reduced, and charges to patient can be decreased.
4. Doctors should then post their fees in the office and online. Competition returns, and fees will decrease overall. Yet profits will still increase. I read about an FP who has done this, runs his office with one PA and one office assistant, has more patients than he can handle without expanding, and makes 2-3 times more than the average for FP's. It can be done! Hassles will be reduced, and medicine will become more fun.
5. Specialists like me will, however, have to get used to more reasonable fees, and still make a very good living, but not have the money to be on all the philanthropic boards, donatebig bucks and hobnob with the politicos, have 6 expensive cars in the family, etc.
The bottom line is that medicine will again become primarily a patient-doctor interaction, and less time will be required for the business of medicine. And if the bigwigs want you to have an EHR, let THEM provide you with one!
This will, of course, subject those who take it on to a temporary drop in income, until their new practice mode and patient base are established. If you're living up to the last dollar of your income, cut back & start saving for it. If you have a nest egg, now's the time to use it to tide you over. Your independence is worth it!
Hi Dan,
Thanx, but I agree with ohioobgyn and how to achieve this ?...agree with Doctor SH.
That aside, I am not sure about the difference between EMR/EHR but, my gut tells me that the EMR is the legal medical record that we create and the EHR is what patients are doing but not telling you about...ie.alternative medicine. Billing...separate issue...pick the clearinghouse that doesn't go down frequently. Strength in numbers...again...agree with ohioobgyn and Sermo Doc 19...
God Speed
Athena, advancedMD , mysis and most of the billing companies have the claims scrubbing and submission features that reduces but not always eliminates the wrong submission ( example: using weight loss an an indication for ordering a CT scan of pancreas!). This feature can be built in at the EMR level but is more efficient when done in a centralized manner as billing companies do.. The only way an EMR will work is if the process of accurate data entry is closely knit into the office workflow( Dan, EHR is where a patient can also input data...I have never found it that useful as a good amount of such "data" has to be "scrubbed"... The least painful and most efficient way of record keeping is to ask patient to keep a file folder and instruct them to file only the very vital information in that file ( No filing of ED and Hospital discharge instructions and 20 page EMR generated trash about "what are the causes of abdominal pain")..In India we used to write clinical history in few lines, list meds and problems accurately on the back of used paper/ handbills( carefully cut into 1/4 size to save money... and the poor illiterate patients would guard this like gold, get appropriate care no matter where they went for treatment. In the US, I send a complete secured digital medical record as a compressed pdf file to patient's e.mail or on flash disk. Unless there is universal patient directed secure connectivity between all labs, hospitals and imaging centers, the cost spiral will NOT stop. EMRs will make life more complicated. All said and done companies like Athena can be an asset to small practices as they bring the benefit of well-managed back-office operations for the cost of a good employee. The nice thing is you pay for what you use. Allows doctors to take off more often and avoid burnout .
MD4 visit IMP group and you will have your answer you will also get convinced: 1- high volume practice is not good 2- 10 ladies moving paper around in our office and doctor sending pt to every specialist and test known is not what practice of medicine should be
EMRs and highly efficient groups like mine did very well early in the 2000s - unfortunately the profit advantage has been eroded by rising costs and static reimbursement. EMRs cannot address the biggest problem which is inability to get meaningful negotiations on reimbursements with insurers. If Athena users could group together into a national megapractice and negotiate jointly then it might have merit. One problem with Athena is that the database is highly proprietary and very hard to very transfer to another EMR if you ever wanted to do that.
Ref : other comments here - yes Balance Billing would set us free, but our politician slave Sermo Doc 26s are never going to "allow" that - the only other option is joint negotiation or cash only.
Ref : doing forms, refills, non visit care for free, simple answer DON'T I charge for all these or require a visit if it is not allowed If the patient doens't like it they are told to go elsewhere.
DP-want to make a real difference? Get the members of Sermo collective bargaining rights nationally and regionally, and we begin the true process of ethically valuing the ONLY thing that matters, the patient-Dr relationship...
Sermo Doc 19 nailed it, succinctly
BTW, EPIC sucks big time, the most disbelievable mish mash info generating time draining GIGO
I have a tendency to agree with Sermo Doc 43 and DrSH. That said, just what would this partnership of Athena and Sermo consist of, and how would it benefit the individual doc here?
I don't think solo practitioners can afford any EMR. I don't think an EMR will help me to practice better. What will help a solo practice physician is the abolishment of interaction with third parties. I just want to practice medicine, without any third party interference. That is it.
I punch and type in stupid notes to document what I actually did, but nothing really describes what actually happened. We have to "prove" we are doing something for the patient, especially if no prescription or test is ordered. Hence we have EMRs to "document" every possible ridiculous thing we've noticed so that we can get some arbitrarily designated sum from a remote insurance company.
I also work in a big group that pushes the insurances to pay for what we do. It keeps track for us.
Therefore, I'm not interested in paying for extra confusing and expensive services by Athena.
Health care money should go toward patient care. End of story.
Sermo Doc 67 I wish I had your attitude. As a child psychiatrist I'm just sick and tired of NOT being reimbursed for the HOURS spent reviewing records, making phone calls, attending school conferences/observations. I love these kids and I put in the time because I believe it's necessary in providing good care, but I also have a family to support. And by the way, I was notified this week that my pay is getting cut 7%- this one month after the agency ended their 401 k match and cut benefits by 23%. Yes I know it's tough all around.....except if you you're a CEO at a healh insurance company.
No the EMR will not improve the position of the doc in this or the forseeable future. The time for the EMR to improve the financial position and provide some relief from the workload of the physician is past if it ever really existed. I've had a working EMR since 1998 (over twelve years) and there were gains early in the game as revenues could be increased by seeing more patients, more efficiently with templates and boilerplate entries .Revenues could be increased with minimal increase in costs. These were relatively simple EMRs and many of us developed our own or at least were heavily involved in the day to day managing of our office networks. The costs were not so great as now if the doc was willing and able to manage their own networks and work more efficiently.
We're now in the age of bloated and expensive systems that are more to the benefit of the payors and regulators than to the practicing doc.
It's a game, and no one understands that. For every action there is a reaction. When doctors get smarter on business issues the rules change by the insurance companies and Medicare.
The reality of the situation is that doctors are being asked to participate in a financial system as though they are in a free market system when in fact, 3rd party payor systems are NOT A FREE MARKET. Don't cloud the waters here. The only way "business" can ever make sense is with the following. Doctor charges patient, patient pays doctor. Anything else is a perversion of free market.
So either socialize the whole dang system or make it so the patient is responsible for reimbursement from the insurance company not the doctor.
The cost of medicine is going up at an alarming rate because of only one reason. Free markets are not in effect. The attitude is always and I mean always, when it is coming out of someone elses pocket it doesn't matter how much it costs when it comes out of your own pocket you better believe it matters.
These are the simple truths of business.
How do I know these things, I've been in private practice for almost 4 years now and will soon no longer be in private practice because of the inequality of costs vs. payments.
Also doctors fool themselves everyday when they think the public really gives a rip about us and particularly our income. The public thinks we're all rich son of guns and deserve a pay cut, so don't ever look to them for help. So your desire to publicize your pole on physicians will only work to ostricise us even more.
There is an EMR system now available that is basically a scanning and sorting system.
Im not going to say the name as Im not promoting anything...but if you are interested search it. It is working well for some higher volume type offices. I dont have it yet...so I cant say...but it makes a lot of sense.
The idea is to NOT change the way you work and document. Still write your chart paperwork...BUT scan it all in and it is sorted to the correct section (notes, surgery paperwork, authorizations, billing info, consents, tests, etc etc)...
So you get all the positives as far as
(1) Never lose charts (2) everything is available and in order all the time (3) Do anything on the computer related to charting that is easy and comfortable for you (4) Scan everything else. (5) Get rid of ALL the paper, but on your own time and scheudule...You dont have to be afraid of an implementation date where you cant do things the old way. You can keep the paper chart if you like. (6) Do your own coding...(how can a computer possibly code correctly?) Coding has too many subjective elements....like complexity.. (7) Patients can use pen and paper and you scan it in. (8) Nothing highly complex to teach staff vs traditional emr
No interfaces with other equipement needed, but can be done...
Can interface with Eprescribe..etc
This way, you dont have to change the way you work..there is NO WAY clicking on a screen is good for pt care....and it absolutely puts out garbage over and over and repeats errors in a very dangerous way.
Instead read your note (ok it doesnt fix your handwriting, but that is a small price to pay)....
think about that concept....very interesting to me. Just looking at it.
The problem with EMR is that it is trying to make you work in the computer work...
Perhaps a separate thread could be started to expand on the development of a viable third-party-free practice model? I would be very interested in this.
The decision to use an EMR should not be based upon the government giving you a bonus payment. As we can all see....since we are about to get a 21% cut....we can't count on any promises from them.
You should get it only if it will actually help you and is right for you and affordable to your practice.
Expecting the bonus is going to be like "Waiting for Godot." What kind of business would actually operate that way...hoping to get paid if they meet nebulous and every changing rules...
I hope your comments are just out of frustration. Why pick on us specialists who might charge more than you? Why pick us out as the villains when we have a government and society full of financial fraud? So your doctor charged more than you thought it was worth I guess?? Was it really that easy or was the doctor skilled and made it easy for you?
How much did your insurance actually pay the doctor? Blue cross is usually a poor payor. Why were the services not wroth the cost? Compared to the cost of what? The average worker (Im not kidding, this is the actual average including everyone from janitor to CEO) at Goldman Sachs made $500,000 net this year. Our government seems to feel very strongly that they are worth it as they keep supporting that and other similar companies with handouts, easy money via handing them treasury business (like bond sales) on a plate.
If the guy fixed your muscle in a few minutes and it worked and you were healed...what is your beef with that...? Do you think some people in society should have a fixed income while others do not?
I think its always a mistake to polarize our profession. This makes us weaker.
Im not wanting to start a flame war, but I will say that I feel people in your field are overworked and underpaid and I support increases to payments to physicians who practice general medicine and pediatrics.
I don't feel that has anything to do with specialists, however...
Its about as different as the cost of gas. It has nothing to do with what you are paid and we should insist that there is not some imaginary fixed "pool" on money for all doctors....where gain to one means taking from another....
Nothing else in society works this way...certainly not in government.
Imagine if there was a fixed pool of money for military (it goes up all the time)...or for government workers salary and pension (it goes up all the time)....or for bailing out zombie companies (seems unlimited)...
Im not going to stand for this concept when the rest of government spending is limitless.
Doctors are paid a very small fraction of healthcare dollars. Lawyers may even take a similar percentage of total healthcare dollars! No one knows.
So tell us what your insurance company really paid your surgeon for your procedure...and stop blaming your premium on doctors...
You are dead wrong. Your premium goes up because our society does not know when to stop consuming. Healthcare, houses, junk from China in WalMart.
Since there are no limits to consumption, costs will rise forever and there will never be enough resources until the day everyone in the country works all day providing heathcare for everyone else.
Your case was cut and dried. You had a problem, it was fixed.
How much...not the charge...what is the allowed amount? Where were you seen....ER...office? Did the cost include only the doctors time, or also office space, staff, suppies. Does the procedure include 90 days followup?
Most EMR's are management/ billing programs with a medical records part. I have Eclinical and find reviewing the chart slow, looking at past meds or injections and the results tedious. Linking the codes is slow etc. I already know what I have to hit in the dictation for a service level. Office management part is pretty good. So for me, EMR has taken the burden off the low paid front office staff and placed it on the high paid docs and nurses- not exactly what I envisioned. To work for docs, the chart program is key.
NO ONE CARES MORE ABOUT YOUR MONEY THAN YOU!!! No excuses to not know how you get paid. No excuses not to understand the basics of a profit and loss statement, balance sheet, and cash flow requirements. My god people, how do you balance your checkbooks?? Seriously, by an investing book on how to evaluate a company. It will explain what to look for in those items. You need to know the basics or you won't know what dumb questions to ask the accountant and you are at a high risk for embezzlement.
Sermo Doc 79 well said. once we begin in-fighting we lose all advantage. we must unite as physicians, not just surgeons vs. dermatologists vs. OB's, etc
Interesting comments so far. Somewhat disappointed that Dan (and Sermo) decided to partner with Athena. I have attended many of athena's webinars over the past 4 years. I like their Payer rating service. But have to agree with sentiments expressed by Sermo Doc 6 and nsmurali. All these organizations like Athena are like parasites that thrive on the complexity of collecting payments for medical services rendered. For the average physician in a small practice, it should be very simple. The problem is that we have no leverage to negotiate with payers; so no matter what we do (with or without help from Athena) we will be playing the game according to other parties' rules. So we cannot win in this game of CPT codes and managed care. We have to come up with a method where participation with insurance networks does not force us to get involved in the coding/billing game. It would be best to collect payment at the time of service, and allow patients to get reimbursed from the payer. This would help patients get access to our service via insurer networks and we get paid at the time of service. If Athena can promise that they will be able to deliver PATOS, I will gladly use their service.
Very simple: just look at what lawyers do. Nobody tells them how much they can charge or that they are overcharging. They are not required to have ELR (electronic legal records). If they send you a bill for $2,000 you write a check for that amount.
They make deals and settlements and sometimes end up getting less money than they were planning but they get it. They charge for their time and knowledge.
Why don't we learn and get rid of all the 3rd party BS and all the regulation, etc.. instead of hoping that more technology will help us.
EMR is like pornography, in the old days we looked at a magazine, now is on a computer monitor, but it's still pornography. Technology just made it more accessible... but it's still "bad for you". Just like the TelePrompTer did not make Obama a better president.
So we'll still get screwed (electronically) with EMR/EHR.
i believe EMRs can work and be beneficial to patient care IF they are universally communicable and accessible. If data can be exchanged between say an allscripts and an amzing charts that is progress. Individual EMRs that cannot data share are not going to improve patient care by decreasing unneccessary duplicate testing. We live in an age where information is at our fingertips all except patient information regarding labs, testing, medications. Give me real time data not wait for a fax from one office to get 'scanned into' my EMR to see it. Paper charts are for the dark ages and no matter how much we long for those things, our society is going paperless everywhere you look - how many of you now do online bill pay for instance?
Patients cannot keep track of medications no matter how hard we try to get them to keep a list. One pharmacy does not know what another has given to a patient which leads patients to use more than one pharmacy and sometimes in those that are in early dementia or just ignorant take extra meds. There is more tracking of behind the counter SUDAFED than there is HYDROCODONE yet hydrocodone still outpaces meth in terms of usage. Link pharmacy data to each other and to our EMR - surescripts is actually trying to do this now which so far is not turning out to be that good but it is heading in the right direction.
If the government wants to force EMRs down our throat, then make them on some sort of standard platform that promotes their communication but not create one of their own like CPRS (although it really is not a bad system compared to others). I don't care if there are more than one EMR vendors, in fact i welcome i as competition breeds improvements, if there was no Apple and Linux, Windows would still be running like their millenium edition :0
Want to keep third party payers? Then they have to accept efiled fee tickets from the EMR. For those who argue that computers cannot determine the complexity of an office visit, I agree, but neither can certified medical coders that review charts, they are not doctors, and they are the ones that review charts at the insurance companies or are employed by large groups to do the billing.. Our EMR has an overide button that you can put in the level of service yourself and not let the EMR generate it. You should be able to generate a list then from your emr of outstanding bills much the same way a paypal account works. Once you purchase something it is shipped and the little package light comes on, the little $ sign lights up after you pay for it, then you leave feedback by clickng the thought bubble. Why can't we send the bill and when the insurance company processes it and sends us the money, it lights up the paid button. This can/will work if someone puts their mind to it, there are much more complex computer programs out there.
What else... oh in terms of althena, i have no opinion on that because I think the problem with the way billing is done needs to be fixed and not adding another person/layer to pay to get my money for me, we already employ/pay too many people to do that already. it should be as simple as submit bill, get paid.
1) If the electronic system is web based, it is cheap, no back upneeds and patients can participate. It can be hacked, but so is the US Military... BFD 2) The electronic system can have huge savings of time if all are linked to it.. specialists, radiology, lab, pathology etc... Like the VA has had for. what, 30 years??? And we privates still have nothing like it.. 3) As so many have said,, this is a moving and unfair game... no matter WHAT you do to jump through all their hoops, the rules will be changed to benefit the insurance CEO's and their stock holders... and diminish your autonomy and income... 4) Bail out!! Cash if you can... This code nonsense is destroying us... timewise, morality wise with the gamers of the system etc.. 5) A wise physician-colleague told me 20 years ago that the social contract between American physicians and society had been broken.. We would give the best years of our lives to amass a large data base of information and techniques, and in return, we would be paid well and have an opportunity to help our fellow citizens in very meaningful ways... For me, over the last 15 years, it has not been the income issue, it has been the loss of liberty/control.. having to justify my prescriptions, radiology requests and referrals to a bunch of illiterate, ignorant reviewers has taken the fun out of the game!!
<oh in terms of althena, i have no opinion on that because I think the problem with the way billing is done needs to be fixed and not adding another person/layer to pay to get my money for me, we already employ/pay too many people to do that already. it should be as simple as submit bill, get paid.>
Could not agree with this more.
If Athena--or anyone else like it--wanted to be helpful to us, it would become a service to PATIENTS to help them submit charges to their insurance, because quite frankly, that's a business we want out of. Pronto.
I think it was Firedoc1 who came up with the new definition of single payor--the new "single payor" is the patient; they pay us directly, preferably in cash--although, I suppose credit cards work just as well.
As a group, we are the whippng boys for the consquences of improving medical care with increasing cost. We, as a group, have not been able to conquer the common quality/financial equation, that any improvement in qualty must be accompanied by a lessening of cost, an increase in efficiancy and and increase in the bottom line. Obviously, the cost of medical is rapidly incraasing, efficiency is decreasing and the bottom has fallen out of the bottom line, at least for us. We can blame the situation on many factors, but the major one is poor management by guess who, you and me. We have , as a group, consisntly failed to meet the challenges of government and thrird party interferance. And no, I don't know exactly what to do about it either.
A simple true life vignette about EMRs from this past week. One of my patients was involved in a fracas and injured his hand. He was seen at a walk-in clinic. Through his Mother I requested his records from that visit (I never saw the patient for this injury) for referral to a peds orthopedist for followup.
The EMR record arrives, informing me in great detail about his ROS and in his exam that he had no nipple discharge and a normal breast exam. Comforted by this info, I tried to determine just what was wrong with his hand. Contusion and LROM, pain. Radiographs were ordered but the record did not indicate an official reading despite a diagnosis of metacarpal fracture. No mention in the treatment portion of the record of any bracing or casting, nor of any followup or referral for care.
There's your EMR. No nipple discharge, but inadequate documentation of the actual injury, imaging, and treatment. I can't remember the last time I checked for nipple discharge with a patient with an injured hand with contusion and fracture after a fight.
And I still don't know which metacarpal was fractured.
My impressions of EMRs - patient records should be maintained on regional database servers accessible by any doc with proper clearance with an individual patient identifier number via a computer with DSL access to the Internet. The EMR should be maintained by the beneficiaries - the Feds, States, and insurance companies - on their dime, not mine. I see the patient, access the record, record my exam, orders, review all imaging , lab tests, and pharmaceutical records as well as specialist referral visits from central data base. The Feds and insurance companies can afford a crack IT team to maintain the universal EMR and the headaches associated with security and other tech issues. I cannot. My solution solves the problem of interoperability of systems and health exchanges. Why reinvent the wheel? We have an interoperable system called the Internet.
How would a small solo rural practice fare with a web based emr when the internet is not accessible a good amount of time. We are not as connected here as they are in some 3rd world countries. I'm all for emr's and but not the kind of info exchange available to Sermo Doc 87 and the clouds are not reliable here. Don't see much discussion of cost of athenahealth system anywhere.
Sermo Doc 87 is correct. Garbage in...garbage out! This doesn't help anyone. Too many hospitals are moving ahead with these systems without a clue. They are being driven by the great promise of financial help from a government that also doesn't have a clue, or for that matter...any money.
Sermo Doc 41, in many ways the Vista system that the VA uses is better. A lot has been written about this. That systems primary concern is clinical documentation. NOT coding and billing. The value of the system was shown in Louisiana after Katrina. People who were veterans who left New Orleans and went to other VA facilities for care had their records immediately available to the new physician in the VA system.
Interesting thread: 1.Hope Sermo is not out to "endorse" Athena; I value Sermo's independence, and got interested when you exposed the AMA for the corrupt bunch of lobbysists we always thought they were. 2. Difference between EHR and EMR: EHR can be patient founded/maintained, at sites such as Google. Whether the patient bringing in this printout is helpful is dubious. 3. From a Grand Rounds at our hospital: Implementation of a full EMR can cost 1/4 million $ and up, and will decrease the number of patients seen (and with it productivity) on average 25-50% in the first year. Many vendors recommend just closing your practice for 1-2 weeks to "adjust" to the new EMR. Dan, I may not know the exact definition of cash flow, but I do know these numbers are unacceptable. 4. Agree that the Fed Stimulus money is a joke. No system has yet been certified, HHS took forever just to publish general criteria, and I think their (the government) ultimate goal is to get inside your office and be able to search through your records at their whim. 5. There are simpler/cheaper ways to just digitalize your current charts and maintain current practice routines. 6. Am also looking at various "supergroup" type arrangements; perhaps that may be the best way to somewhat stand up to the insurance companies. Perhaps you could report on the different options and experiences with these arrangements.
My state society meeting was last week . Our lobbyist made it very clear to us that the politicians do not care about physician incomes . The politicians only listen and notice the PACT contributors .
My daughter recently had surgery . A week prior to her surgery , the doctor's office asked for her credit card authorization to bill the balance of her surgery bill . The morning of surgery the hospital estimated and billed my credit card for her hospital bill . An OB GYN I know now asks the patient at time of visit to authorize credit card for any services not covered by patient's insurance.
Physicians in private practice are running a business.
The only way to regain control is to go back to fee-for-service.
Then your customers/consumers/clients will go back to being patients and you will be a physician again and not a provider.
Presently we have no control over our expenses or our fees.
At least wirh control of our fees we can raise or lower them as costs change.
In turn out patients can then put pressure on the insurance industry/lawyers/politicians/government to help control the costs to physician of providing medical care.
Right now the physicians are the "monkeys in the middle" with all control bypassing them.
Do I think this will happen? Nope. Doctors will never agree on anything.
And to those ideologues who are going to tell me about "The Oath" I took........
Get a life it is nothing more than an ethical guideline and ceremonial in nature.
It also isn't taken by all physicians and there are different versions.
So don't bother with that worthless "pap".
Fact: The U.S. is broke. Healthcare is a major threat to the financial health of the nation in all of its iterations: medicare, medicaid, and the healthcare system. If you read the comments by our colleagues in this column, there is no discussion of bringing healthcare costs down or even under control. That is why we have been marginalized. We have nothing to say. Most comments deal with ever more complex tools to manipulate the system to extract more dollars, e.g electronic records, larger groups to bargain for more power. The system we live in is broken because of its complexity and its dominance by the insurance industry which has no place as the means by which we finance our health care. Insurance is a financial tool for protecting assets based on risk. Risk has no place in determining your access to healthcare. Solution: Get rid of insurance. Every citizen should have access to health care. No mandate needed. Insurance companies have the system by the throat. We can finance healthcare with taxes in a progressive system. Second drain on the system is fee for service. It has to be replaced. With what? Salary. Every physician in the system would be compensated in a scheme that recognizes education, years of service, productivity. They should be employed by regional health centers or regional clincs. What are the merits of this proposal? First, it is simple. Second, it reduces cost by removing the two principle drivers of cost: the insurance industry and the fee for service system. How will we do it? We will be forced to do it because we cannot afford any alternative.
By the time I got here, there were so many comments that I am sure I am being repetitious.
I am against the EMRs. For our small practice already in debt, the cost is horrific.
we have exellent templates my husband designed and our notes are clear computer printouts. I simply do not have the cerebral connections to stare into a computer or scratch things on a hand held while concentrating on my patient. My programming does not work like that.
I need to look at my patient, connect with his/.her eyes, gestures, grimaces to get a really good history. I need to concentrate on my p;atient. Have had peo;ple say "no" when asked about rectal bleeding, for example, but is is said in such a way (guess it's my theatrical training) that I know I have to pursue that line of questioning. And it turns out, maybe they said no as they don't have it all the time.
With our method, I can make quick little notes on our template and then later add to the notes and print them out. works well for me.
EMRS are not without error. Seen by everyone.
Maybe someone was obese and did not exercise ten years ago, had high blood pressure. Since then lost weight, exercises, BP jnormal without exercise. WTih the EMR, it remains forever. Our records need to be kept for only a certain number of years. I have had this happen and patients penalized.
I could go on and on....but we are leaving at 3AM for Breckenridge....and I will be computerless as we need to conserve weight on the flight.
Oh, and another thing..;..before I pack (which I hate). EMRS are automated and often I get reports from specialists who have them...and things are checked off which are inaccurate...such as "Breasts:normal without mass" on a patient who had a mastectomy and no implant.
another: "Allergies: denies all allergies to any medications." This is a patient who developed STevens-Johnson syndrome after having sulfa.
These things do not happen in our templates. of course, you can attack me for errors...we are not perfect...but we do a pretty good job without EMRS
I think I am screaming. I had better go have a cup of chamomile tea to calm down and then pack so we can leave at 3 AM for the Ft. Lauderdale airport
Scimitar...That was tremendously funny! I laughed out loud, but my staff thinks I'm nuts anyway.
Now that I got that out of my system, speaking of "systems", it is quite funny to see some of the letters from specialists. They use templates of some sort, with dictation or EMR. For example:
Dear Dr Sermo Doc 75:
I saw your patient, Mrs XXXX, and....etc etc....
Thank you for allowing me to see this most pleasant patient.
Sincerely,
Dr Specialist
The attached H and P indicates that Mrs. XXXX is:
"An overweight female, BMI of 40, who is alert and cooperative, and *smells of urine*."
EMR/EHR can, if done well and at no great cost to the physician, improve efficiency. However, because it reinforces our dependence on the current coding format for 3rd party payors, it could make it more difficult to extricate ourselves from the whole 3rd party payor mess. I'd like a quicker way to document (and not just for payments or liability issues: I have no short term memory), but what I'd really like is the time to spend with patients and to be able to set my own fee schedule.
We as physicians need to be pro-active in EMRs. They are here to stay. Either participate in changing the laws or be involved in the development of the EMR machine. I understand all the frustrations. However, this tehcnology, used in the right way and developed by us, the end user of the product, will decide the utility. For now big business and big government continueto tell us what to do instead of the other way around.
Not commenting on the practical usefulness of the potential benefits of technology, I believe that the battle for the freedom of the profession has to be fought on moral grounds so that we may have a fighting chance to stave off the complete enslavement of the profession.
HEALTH CARE IS NOT A RIGHT!
A Right is freedom of action in a social context. A Right is NOT a license for extortion of benefits from others at the point of a gun or by Government edict, also by force. In a free society the initiation of force is banned. That is why the Founders after enunciation of inalienable rights to life, liberty, property and the pursuit of happiness indicated in the Declaration of Independence: "To secure these [individual] rights, Governments are instituted among men". The Government is vested by the governed with the monopoly on enforcement, but only in retaliation versus criminals and foreign aggressors. All initiation of force by the Government is unconstitutional. - It is clear that the Founding Fathers talked about the only sovereign in America, The Individual.
Our Government at 200 years later is evading its purpose. The protector of individual rights today became the monstrous slave driver intent on eliminating the last remnants of freedom of a once proud profession. - This is the battle that we must fight!
EMRs can be helpful. But, as a solo doc in private practice who does understand cash flow.... The major problem is that people expect to get good care and pay very little for it. Practices are threatening to opt out of Medicare and at the same time
patients call me with no insurance, wishing to pay cash.... And to make it worse, 'our association', the AMA has helped institutionalize medicine with, in particular, procedure codes. Any doc with enough time can load up a visit note with enough irrelevant facts to make all visits a 99214! I think the 'system' has not melted down far enough that people will really get together to fix it!
It is so interesting to see what a polarizing topic EMR/EHR has become. I agree with the sentiment here in the community that people are too focused on the technology/features and not enough on the work flow/financial ramifications. Here is the interesting thing.....in the Athena-Sermo PSI, we were pretty shocked to find just how optimistic physicians are on EMR. Quite the contrast to some of the sentiment around here. It appears that the key distinguishing factor is whether or not the physician has implemented an EMR (go figure). Physicians who have successfully implemented an EMR have remarkably positive views on the technology's impact on their practice. That being said, we also found there is a tremendous amount of consternation about upfront cost and implementation complexity.
Dan and Athena: The problem Athena and all other billing companies are going to face is the rapid nearly 25% decline in physician income starting this year. Traditional 5-7% billing charge is out of question for any reasonable practice. I have done my math. The sweet spot for delivery of high quality billing services is around 3.5-3.8% of he amount collected. This means nearly 50% of the work (f correct coding must be done at point of service using hand held devices capable of reading 3D bar codes off a record.This encoding must include complete demographic info for billing, even perhaps biometric data, verification of benefits even before patient is seen). Unless medical practices can be transformed into a UPS like organization with centralized design of databases, real time data collection and real time charge for services, I don't see much hope both for medical practices and billing companies. The CMS, EMR, Insurance lobby, Pharma all screwed up big time. They missed out on a very unique opportunity for high quality national ID card that could be used for a variety of services including health information exchange. May be we need to outsource this stuff to Nandan Nilenkani! If India can do this why can't the US?
Dan: I am not sure who your group of docs were, certainly not me. I have nearly 8-year experience operating a fully electronic office (we don't have a single paper chart, never did). We utilize our EMR to facilitate our work-flow tremendously. We cannot imagine running an office without one. Frankly I don't miss writing (I was a lousy writer anyway). I could show you a hundred different things our EMR helps us with, most of which we could not do manually. That does not mean we make more money than if we just scribbled on paper. We do save about 20K annually on transcription alone, and our EMR allows us to operate our office with a physician and a CRNP using only 2 FTE MAs. Show me a way to get paid more for our services, then I will agree that an EMR is worth it financially. If you decide to implement an EMR purely based on financial expectations, you will be disappointed, whether it is Athena or otherwise. Remember, Athena is well-known for being an aggressive for-profit company (a darling of Wall Street). So helping physicians is probably low on its list of priorities.
murali, I'm not recommending Vista, and you are correct about the VA...a model for America's future? I certainly hope not.
Sermo Doc 82, practices such as yours and others that have diligently designed and implemented systems that work should be congratulated. Most physicians are not tech savvy and will need an intuitive system that may have to be customized for the individual practice, but interfaces easily with anyone who can use a computer.
As we have learned in almost 4 years of a failed attempt, you must pick your vendor well and have excellent local IT support, as well as a willing staff to be successful. We had critical weaknesses in all areas. I have learned a lot. And, we are currently on hold. Our entire in house architecture is based on Windows XP SP3 and we can't move forward without starting over. We scrapped the office EMR system and forced the vendor to refund the entire investment...which they did. We are functioning with a lab system, PAX, digital dictation and a functioning schedular tied to a basic paper record. It works for now.
I'm meeting tomorrow with our regional referral center about a number of topics. One of them is their forced installation of a new Mckesson system that has been thoughtlessly introduced and is failing before it even gets off the ground. The administration didn't do their homework. This is not an isolated occurrence.
I hate doing progress notes on EMR. I'd rather check off things and write indecipherable notes on the bottom, really quickly while I'm gazing at the internet. Actually, there are good things and bad, and I like the fact that I don't have to write in a bunch of words explaining how the lymph nodes were. I can mark on a diagram of an unrealistically trim healthy person where the pain is. The infant picture to mark things, like where a rash is, actually made me smile.
There are multiple problems, however with our EMR, which is Epic. The main one is lack of friggin communication between facilities and doctors who don't have our system. Now the big affiliated hospital is hooked up with us, and most of the specialists and their offices, but outside...stupidly no.
So we still have to scan in dozens of labs, ED notes, hospital stays, consult notes into our system daily. We're behind on scanning by over a month now, due to three other doctors here. It's a mess.
As far as payments, I have this very nice but assertive Italian-American lady as a manager who is very open to telling me what a blockhead I am if I continue to see patients on the Doofus Inc. Plan, etc.
Sermo Doc 75, we just bought another 5 gazzillion terabytes of storage for all of the stupid scanned documents and they can't even keep the paper records straight! My friends who operated in war zones had better communication,
Interesting topic! Will utilizing and EMR/EHR improve financial independence? I doubt it. Based on current costs of providing medical care and the payors (all of them private and public) willingness to pay for care, will we see our prospects improve in the future? I doubt it.
I am in a small group practice, Orthopaedic surgery. We have always have an electronic billing and accounting system for patient accounts. We have always done our own billing and current collections. (Grossly delinquent accounts are turned over to a collection agency) Our collection percentage is in line with national averages and our A\R are up to date.
We are using the government stimulus to update our electronic systems to a fully intergrated EMR/billing package. My hope is not that this leads to a pheonix in collection and income, but that after the system is implemented and the templates are all worked out is that our efficiencies improve. I want to write and dictate less. I would like to spend more time devoted to treating patients, and less to dictating letters of appeal for denied claims. It is true that we hope to save over $25,000 dollars yealy in dictation expenses. I am hoping that the EMR will make me a better, more accurate and more efficient physician. Not necessarily a particularly wealthier physician. While I am no champion of healthcare reform (nor healthcare payment reform for that matter), if Mr. Obama through the economic improvement legislation is willing to pay for over 80% of the costs of a fully implemented EMR billing system for my office, then I'm willing to try make it work!
Moving forward without intra-operable systems being 'sine qua non' is simply foolishness.
As Sermo Doc 6 said, if there were an intuitive, effective tool available, no one would need to 'push' physicians toward it.
Most - perhaps all - EMR/EHR notes/records I have seen have been an insult to professional medical care. Anti-intellectual would be kind.
I DO believe that computerized records COULD be a boon - professionally and economically. But I do not believe current iterations are.
The current trend of designing EHR to supplicate and facilitate CPT is only likely to enslave healthcare professionals.
Let congress 'demand' that EHRs be designed to 1) intra-operate and 2) FOCUS on the doctor-patient interaction (NOT the CPT-specs of that interaction), and this could have a benefit to patients and doctors.
for Sermo Doc 1 Thanks for the compliment. Regarding "supergroups" for OBGYN in the Northeast, I know of two- one in CT, one in NJ; I believe each has 80-100 docs who bill under one taxpayer id; that gives some weight in negotiating with insurers; for doing the billing, I think they get roughly 5% of collections; there are also potential reductions in liability insurance and purchasing economies of scale; they try to otherwise let each practice continue as it did before joining, but in some cases have some practice guidelines to follow. Each practice that joins usually controls hiring at their own location. You have to weigh some loss of independence and their commissions versus potential increased reimbursements, other savings, and having to manage less in your own practice. From what I can see, there is even some choice for member providers as to which insurers to accept in network. Again, this might be an interesting topic for Dan to explore. Our group has just started to look into this.
AZ drydoc is on the right track. The only thing that will save us is so politically incorrect it will never happen. We have to get all third parties OUT of our relationship with our patients. Medical insurance must be limited to its original status (50+ years ago): a contract strictly between the patient and the insurance company. No assignment! The doctor renders the service. The patient pays the doctor. The insurance company reimburses the patient according to what the patient bought. Afraid too many patients will simply pocket the payment? I can handle that better than I can handle the endless hassels and headaches from the insurance companies. What happens to fees? I could lower my U&C fees about 40% and my blood pressure about 30 points if I did not have to deal with all those miserable third parties. Medicare is the worst, but Blue Cross and some others are working hard to catch up. Why don't I just do it? 1) My partners don't see it that way (heads in the sand), & 2) I'm too close to retirement to start all over. If we keep heading in the current direction, even with a few delaying actions, we will all end up working for Uncle Barry et al at janitor's wages.
I think the best way to look at EHR is to think of it as a dumb scut monkey. It can and will save a list of tasks to do, provided you type them in.
A very well designed interface can GREATLY reduce the number of keystrokes to get the job done. The problem is that it takes a very bright person to merge the science of databases with the knowledge of medicine, workflow, archaic CPT and ICD 9 codes.
It takes a genius to set it up to take less time and effort than a well designed paper template apparently.
That as such has yet to occur. We sadly await the birth of this template designing messiah to liberate us from the evil oppression of the current archaic systems.
How much per year does it cost to maintain an emr and deal with all the IT problems.You say you save 20k on one end but your probably not far off spending that for maintenance and technical problems.Yes it will be the law and we may all have to have one.It doesnt mean its better.It will serve the govt and third party well for denying payment to physicians for quality measures that dont get done due to patient choice.NOT BAD DOCTORS.And we will continue to foot the bill because thats the PLAN.
After the market closed Athenahealth announced that fourth quarter results will be delayed while the company's auditors investigate whether it was amortizing deferred revenue properly.
In a news release, the company said that right now when it receives an implementation fee for its software it only amortizes the payment over a year. Auditors are looking at whether it should be spread out further. A shorter window would have the effect of boosting reported revenue.
Athena is best known for its omnipresent CEO Jonathan Bush, a media darling. The company's business is dry; it sells practice management software to doctors and collects a portion of revenue that it bills insurers. It has recently been recasting itself as an electronic health records company--a hot area ever since the stimulus bill in February included $20 billion in Medicare subsidies for doctors who go digital. The story had been working. Before tonight's drop, the stock traded at a lofty 53 times earnings.
I love computers; I have used them in my practice for twenty years. But no one has yet developed a computer program that HELPS me get my job done. They are designed by computer people, who don't think like we do. They force us to work the way THEY think we should think. There is nothing elegant, efficient or even professional about computerized medical records. Until the process FOLLOWS the doctor, instead of LEADING him/her, computers will be clumsy at best, expensive nightmares at worst. I typically spend more time documenting an encounter on the computer than I actually spent with the patient, which is unacceptable. Someday, maybe, but I have yet to see or use a system that I could in good faith recommend to a non-computerized doc. They work for the government and the insurance companies, but sadly, not for us or our patients.
Sermo Doc 78 has it right. EMRs are being pushed simply to allow easier audits, searching for ways to downcode and deny charges. There is simply no other explanation as to why anyone would adopt a system that requires MORE doctor time than paper. My brother has an office practice, and spends 1-2 hours after office hours end just completing the EMR.
Physicians don't need to be like business people. It is the conversion of the profession from a profession to a business that has brought many woes upon us. We have a heart, with compassion for our 'customers'. Check out such well known business examples as BOA, FNMA, AIG to see what business men are like.
We do, however, need a good grasp of how we earn our living, and we need to remember that we sell knowledge and experience. A certain amount of 'free work' can be tolerated, but too much will bring down a practice.
The public is basically 'average', and is subject to those basest of human emotions, envy and greed. While they like us well enough in our office, they can't wait to decry us at their local beer gathering. The entitllement mentality of the socialists, beginning with Roosevelt and greatly expanded by LBJ's great works, has resulted in the public feeling that all their medical care should be free. We should 'serve' them freely, not in a for-profit mode. It has taken the socialists 60 years, but this country is now 'there' in their thinking. This august body of our populace sees nothing wrong with wasting millions upon millions of dollars on sports figures (with perhaps 3 or 4 years spent learning their skills out of high school), but resents us charging anything at all for our skills learned in 12-18 years after high school. Our younger colleagues' incredible debt load is astounding, but garners no sympathy from the ignorant masses.
This cannot be changed. It is the nature of the beast. As for me, I am getting out soon. Thousands of my generation will take early retirement to escape this. Our profession will continue to deteriorate as the public crushes it with antipathy and indifference in deference to their own collective desires!
I wonder with incredulousness where Obama thinks the extra physicians will come from when everyone has medical insurance and floods the offices and EDs with sniffles and fibromyalgia! Botique medicine, anyone?
Returning to Haiti is looking better everyday! NO, just kidding. We certainly have a grand mess....and it seems clear that it's come about due to the government's involvement, starting with RBVS...then 450+ codes (sold by the AMA)....to now, socializing it all the way (hidden in an > 2100 page bill).
EMR / EHR is merely a means of corraling us all together digitally...so that our data can be scrutinized / reviewed / used / managed / and maybe even "paid for", sort of.... It is NOT about patient care, as we are being sold / told. This is a lie. As medical "record" is is very poor....and is fraught with pressures and temptations to act in fraudulent ways. It's used to "build a billing foundation"....to jack up the ability to "code higher"....even if the "checked templates or defaults" were not really all a part of the day's visit. It's hard for doc's to admit this is going on, but we who are honest about its construction and usage know what I am referring to. "Cookie cutter" patient visits are pumped out of EMR / EHR. Enough said.
Doctors need to all reconsider their primary first calling, if you will...and refuse to be sucked into "the business of medicine". It's a great profession that will not always guarantee a "good living". So be it. Sure, we need to fight for fairness. Sure we need to try and clean up the insurance messes and abuse. Sure, we need to try and limit government's involvement and intrusion. Sure, we should try and have input into the debates, but....at the end of the day, we need to be able to look in the mirror and know that we, physicians, have done the best thing for our patients and given our all on their behalf.
Sounds ridiculous to some, I realize, but we must not allow ourselves to be sucked up into the "business of medicine" debate to the point that we loose our ultimate focus. We need to be good stewards of medical resources, be honest and fair in our personal dealings, and care for our patients.
Sermo Doc 11 and ramstrong have hit the nail on the head. The wake-up call needs to be a Tea Party like organization of a large number of physicians. Our only effective action will likely be a strike. Let's admit it and get organized-if we're strong enough, we may be the ones who can be responsible for not having to take the "nuclear option".
We need to trash everything that has nothing to do with patient care and start all over. The 21% cut is a blessing in disguise... I wish they had implemented the entire 41% cut this year..and ended the socialized medicine with a clean slice of the head..( I cannot believe that nearly 99% of the doctors I speak to are not even aware of the projected additional 5% per year X 4 years already approved and mandated) . In the list of useless things E.Prescription tops the list, then you have EMR, CPT, WRVU, RBRVS, CCHIT, Billing and then trying to collect, Bloated staffing to meet unfunded mandates..I should end by saying ARRAgh!
The EHR integrated to billing software needs to collect real payments from EOBs and then show it back to the doctor, attached to your schedule.
That way, you could look to see what you got paid at the end of each day, the end of each week. When you looked back to see a day where you busted your ?ss, but got paid very little, you could poke around, encounter by encounter to see what you did to NOT get paid.
This would help us understand who and what pays and who and what does not in a format that we can understand.
The best of the least expensive EMRs that I have ever seen was based on scanning technology. You write your note on paper the same way that you always have, scan it into the EMR, and then, put your note back into your paper chart .
(EMR / EHR is merely a means of corraling us all together digitally...so that our data can be scrutinized / reviewed / used / managed / and maybe even "paid for", )
Absolutely Sermo Doc 15. You are right.
I am in a clinic of many doctors that have started Athena 1 month ago.
I am very computer savay but I am functioning at 50% now. I will eventually get to 60-70 %. But I will never see the patients I used to see. In times of problems of healthcare delivery, why are we being more in-efficient?
Most of us say we see reems of typed words that are meaningless. Our hand written notes are more descriptive and I can remember the patients and their visit very well. I can't remember all those typed words generated by one click of the mouse and I now ignore most of my previous encounters since I don't have time to scroll through screens fo the computer and it does not have meaning to me. I now just see the patient as if a new one or what I can remember. It is sad we have come to this.
The chart becomes reems of meaningless words that are as mindless as the 2000 page healthcare bill before congress.... God help us all.
I agree that eliminating insurance companies should (along with tort reform), be the number one focus of physicians of all specialties, not to increase reimbursement as much as to get rid of the incredible HASSLE of insurance company hoops. My records on patients with Medicare replacement plans are being audited--who knew that lil ole solo practitioner me was felt to be committing fraud and abuse in my small town. Oh, actually, I think Humana calls it "ensuring quality"
The problem with making patients submit claims to insurance companies is they can't figure out the maze any better than you can, and they will keep coming back to you to get more "documentation".
And if physicians post their fees, what will stop some doctor from having a "$10" special? We don't need to compete with each other. Doctors already do that, and it has worked against us, because we do not speak to Congress or the attorneys with a uniform voice.
The last thing we need is another layer of complexity with another consultant like Athenahealth. Smacks of the AMA.
We drank the athenahealth koolaid a long time ago. We have convinced a lot of practices to sign up with athenahealth. Athena helps diddly squat.
They and their rules engine are NOT any better than comparable billing systems. Their main focus is on giant practices / CVS redi clinic/ giant urgent care etc.
They are not bad. They are average/mediocre. Their so called rules engine is pretty ignorant even after all these years. At the most basic, it doesn't know when a pre-auth is required and when one isn't. Doesn't know individual medicaid rules even with doezens of practices from that state being in athena (eg: in our state medicaid won't pay for more than one 99239 per patient within a rolling 30 day period)
Just a fricking useless thing for most of the big headaches.
And the implementation is a big pain.
If you are a half decent doc on top of your billing, you don;t need athena and its attendant headaches. If you are too busy to look at your denials, athena won[t help you and might make your situation worse, because if your claim fails athena rules, athena never even submits the claim. It just sits in a bucket waiting for you to fix it.
Lets not market athena please. I realize Sermo needs revenue to run. But athena could be the new CPT, another powerful albatross.
The problem I see with companies like athenahealth are the fees charged. They charge a "flat" fee per physician and per physician extender, PLUS a percentage of my collections. I felt the percentage was too high (greater than 5%). I view these companies as preying on us physicians. Certainly they are providing a service and they need to be profitable too, but sizable annual flat fees PLUS a large percentage of my collections? Not for me. I will be using a company which offers a software based approach. So I will have a sizable "upfront" cost, but with a smaller, more reasonable annual maintenance fee that is NOT tied into my collections.
Like I said before the value of EMR is in its efficiency and ease of use. Perhaps I can afford to I say this because I do not have to bear the costs. So yes the iphone/blackberry is more expensive than the reg. cell phones and they are more expensive than the house phones and they are more expensive than letters and doves but we wont give them up because tech does make our life easier. So lets not waste energy on this battle Is there a way the Sermo community can effects the dictation of the insurance on us? Can we effect tort reform? Can we give patients more responsibility for the lifestyle choices instead of penalizing the physicians who kindly accepted them in their practice? (by insurance witholds and P4P) We are the public as well, not one of us would dream of not buying medical insurance for our selves and family and so right now we are put into a position to accept an inferior product both as consumers and providers. We don't need to go to business school all we need to know is who butters our bread and which side it is buttered to get to the crux of the matter
I have had EMR since I came out of residency 10 yrs ago, and it hasn't helped me get the money that medicare owes me! They still have the option to just deny the bill stating they don't like something about the claim submission.
I devised my own emr in the mid-eighties. It works fine for me. Payers insist on going through clearinghouses, which muck everything up, and charge for the privilege of being mucked up. Physicians simply don''t communicate well.
It takes me approx 1 hour and 15 min to dictate 25 charts into my VR system. Very high accuracy. It takes another 10 min to read over and correct some mistakes. Work done ..! everything prints correctly formatted with digital voice signatures. The young lady in the office sticks the stuff on letterheads and files the document chronologically into pdf file. I dictate really fast. It allows clean and accurate documentation with no template BS.
As a member of a group ,My cost center now gets charged over 2000$/mos just for the pleasure of having Athena.WE dont have an emr yet..A ceo has just been hired to help implement it....Another 2000$/mos from my practice.Along with 9000$/mos for "adminstrative charges "from the group.Does this sound like a recipe for success?I dont think so.
The FREE EMR in the "cloud", such as PracticeFusion, is the way to go. Costs not one penny and has amazing functionality. Do not buy ANY EMR. None are ready for prime time. The free one is better than any of the 1500 mutually non-interoperative programs being hyped and marketed to the gullible.
I do NO billing and opted-out of all government and insurance programs 12 years ago. Life is good. Taking good care of one patient at a time without any third party hassles restores the doctor-patient relationship, and lets me keep all the money. Practicing Medicine is a joy and priveledge again. My liberty trumps everything.
EMR's are great for playing the "billing game". They are not so good for transmitting essential data to referring physicians that are useful in treating the patient. They do pick up and occasionally prevent drug interactions.
Re:EMR's are great for playing the "billing game". They are not so good for transmitting essential data to referring physicians that are useful in treating the patient.
I agree!
I used an EMR for a while (stopped when EMR company went bankrupt). I loved it, but IT DID Not SAVE ME TIME in creating the medical record. I've seen the notes of many who say the EMR saves them time. Most such notes are propagated repetitions that tell you little about the uniqueness of that patient visit. The educational value of EMR generated consultations is lost because rarely does the EMR generated note document the consultant's reasons for his/her decision.
I will get another web based EMR when one is affordable again. It does save time on the back end (no looking for charts, no dragging charts home to complete, etc). Nevertheless, unless you are content with "cookie cutter" notes that tell you relatively little unique clinical information (especially with the complex patient) expect to spend more time not less creating most chart notes.
Also, I found the cost was a wash. The start up and maintenance cost were such that I did not save money. Large groups and hospitals may get around some of the cost by having in house IT people.
With respect to EMRs and quality the jury is still out. There have been articles supporting both sides of this issue. Suffice it to say EMRs are capable of contributing to major errors and quality issues. When the errors are due to design issues it has not been settled yet who is at fault (the physician vs. the technical people-new malpractice issues).
There's always been a dichotomy in charting, wherein some of the chart notes are for the doctor's use and has useful medical information, whereas the rest is for billing purposes and legal posterior covering. With the EMR, the divorce is final. There is no useful or credible medical information.
I can't tell you how often the EMR notes I receive from inside and outside our practice have absurd contradictions. Retinal detachments with normal fundi, nuclear sclerosis status post phacoemulsification, surgery dates in the future, signatures by doctors who have never seen the patient....
The only good news is that when the system is down and the EMR unavailable, one can't tell the difference, as one has no notes (worth looking at) anyway. Every patient is a new patient, but you can only bill them as established!
I'm married to a professor of Finance, he is additionally licensed to sell and buy big money on the markets. His advice to me, cash. He thinks the nonsense we put up with is absolutely not reasonable. No amount of hard work and education will change the fact that it is an impossible business that no amount of education on my part will help. In short he tells me I would be a Holocaust victim in another time, just sitting around smiling saying, it can't really be that bad, until the door closes.
Perhaps, the public is jaded towards physicans, but these are hard times and the real unemplyment rate is well in excess of 10%. To them, we have steady work and good income. In other words, we are "fat cats". This leads me to a point we should not forget. It is our indiviudal efforts -- going that extra mile for tthe patient -- that keeps our reputation in relative good standing compared to lawyers or politicians. We cannot afford to lose this advantage. In regard to the EMR / EHR, I suspect we have little choice. At the very least, these technologies will keep costs down and this should improve the financial health of physicians. But I think it will not "make money". This is analagous to the article "Hospital Computing and the Costs and Quality of Care: A National Study" which was feature at this web site several weeks ago.
Sermo Doc 78 --- if by ''private practice, you mean solo practice,....do not change and join a group unless you are doing so for other reasons besides $$$. Life is too short to try and find our true satisfaction through monetary gain. Hang in there with private practice...
wecaras -- I completely agree with your thoughts about "going the extra mile" for patients. And, in my opinion, many see "doctors" as the rich....as, in fact,....many are. Many docs have become so accustomed to their nice incomes, that they personally justify them...and argue for even improved incomes....or at least sustained incomes....in the midst of rampant unemployment, a government that's going to outspend any and all other governments, and disasters affecting the poor around the globe. We, as a profession, are probably not deserving of "being felt sorry for".
We are privileged to be physicians and should help one another remember our calling, if you will. To serve others. yes?
I would beg to differ. I started my surgical practice almost 5 years ago with hospital support. In that 5 years I have yet to take home what I took home as a military surgeon. y wife's partner who started an OB practce in the same area took 3-4 years to take any money home.
Physicians may be highly paid but they are usually from specialists in downtown urban areas. Most private practice docs in rural america do not do nearly as well.
Remember also that if physicians start taking cuts we will be forced to layoff employees thereby contributing to unemployment. Charity coerced by government is not charity it is slavery.
I think it is quite the opposite...what is being offered by AMA/Ingenix/Dell has very little to do with patient care and much more towards minimizing physicians' role in taking care of patients
EMR are greatly helpful in keeping records. It delays my day by several hours each day-may be I am slow. It does take away time with pt care trying to document while in the exam room with the pt. The bottom line is the E&M codes that makes my life miserable, There is no proof of what care you have provided unless documented. What about all the extras that we provide -unbilled services for our pts-after hour calls etc.. ? There is no account of all that. sometimes very discouraging when you want to provide quality care to your pts especially the older ones with hearing impairment, visual impairment etc... one cannot rush from pt to pt. At the end of long day I am left with documenting every spoken word on the EMR just to please the medicare auditor. It is time to change the system. Make it simpler so we can perform our duties and enjoy our sacred profession.
Sermo Doc 125.....I hear this frequently...takes along time to do documentation with emr.Physicians have to reeduce patient load ...or they never get out of the office.Also implementation is a nightmare...my group has started rolling out nextgen....major problems.MAJOR.
Dan , you seem to be having a conflict of interest here. As most of the docs here want to do away with third party payers, why would you want to join forces and promote a group that helps collect from them?
That said, I need to stay out of this because I am a part-time doctor paid by the clinic owner / manager.
Although our practice is an exception and has some very techno-savvy docs and practitioners, we have despite a large investment in EMR, disease management, and IT seen only increases in costs without profits, largely due to ongoing declines in reimbursements against inflation and other costs (including health care).
The resistance to a shift for paying for work when the patient is not in the office is the problem. We can do 50% of care without them in the office, but can't get paid for it. The biology of the human mind is also a factor because even if it will save them money and time, people are averse to paying $50-$100 and avoid an office visit.
The EMR has helped in the hospital mainly with PACS making time to review imaging properly more streamlined, but this has easily been offset by decreased inpatient reimbursement and the need to maintain a steady office practice or suffer losses from failure to use the resources in the office while at the hospital.
Billing technology per se does not help. We can send all the clean claims we want but continue to be either underpaid, or face ridiculous denials and delays, which appear to be organized crime on the behalf of payors. Our billing overhead continues to run over 15%.
I have watched the average specialist in my area either (A) go out of business and be bought out be a larger entity (75%) or drop staff and refuse to deal with complex problems (15%), leaving only a tiny minority like us to deal with complex care. The truth is that now you are paid more to shake someone's hand and do nothing, or do a well reimbursed procedure of marginal benefit, and say "hasta la vista."
I predicted the Medicare system would self-destruct last year, since the average MD lost money in 2008 and 2009, and now we are looking at no serious action to be taken with most even though they will lose more this year. I am amazed at the lack of action.
The goal should really be to streamline our ability to spend time with patients, document what is actually done for them at the visit and then bill appropriately for the time and effort of the physician.
The model that lends itself, in the purest form, to this transaction is cash. The cash, in the outpatient setting, could come from a credit card, HSA, checkbook or wallet...it doesn't matter. Then you could throw the current EMR system into the dumpster where it belongs.
When an intuitive EMR system is finally developed, that helps physicians practice, like your iPhone just works, doctors will not have to be forced to buy it or use it. That should be the goal.
Do you want to start a "Business for Physicians" program for residents? It will be a 1-2 week course educating them about what they need to know about business side. Conducted at various locations by rotation. ... or on internet by webinars.
I will be glad to devote some time preparing the syllabus/material/presentation.
The intrusion of third parties into the physician-patient relationship has become a crushing burden as Sermo Doc 5 mentions above.
As a profession we have seen all sorts of industries develop to help us deal with the third party payment system to "optimize" our reimbursement.
I would submit that the third party payment system IS the problem. It is the problem that the health reform bills fail to address, or for that matter even understand.
So, how do you think the current group of students/residents will feel about having to take this mini-MBA course to figure out how to survive in the lethal business atmosphere that has been created around us for the past 45 years? If they correctly decided to not participate and follow another path...who could blame them?
We need to change this completely, not just accept it and figure out "work-arounds".
Physicians MAY be in same financial situation next year
God save the Queen
But they do offer the opportunity to free ourselves from the present system . . .
We have no current organization that speaks to our needs, and we are unable to collectively voice our concerns and be listened to by the public and others who might want to help. One day, when the public suddenly finds that medical care in the U.S. has deteriorated to a dangerous level, there will be a wake up call. Thank goodness for Sermo which is trying to help.
Jegee
Charge for our time like the lawyers do. So paperwork and phone conversations become billable, and we get reimbursed for the "cognitive" part of the work.
Charge for procedures like we do now, for the procedural part of the work.
Trying to bundle the two together does not work in the real world.
Also we need to fight for the cognitive turf. Allowing every Dick and Harry to bill for 'cognitive medical work" will bankrupt the system. Only properly credentialed board certified physicians should be able to bill for this. Counselors, nurses, homeopaths, naturopaths, nutritionists, etc. etc. will quickly bankrupt the system IMHO. Those mid level practitioners should only be able to bill with the signature of the attending physician for approval. JMHO
It is not in place for the patient, but for the "business of medicine"....which I guess is your topic here.
I just had a distal biceps rupture, while helping in Haiti....and the bill thus far, for its 45 minute simple repair.....has just about converted me to a Democrat!!! Where these hospitals and specialists come to think they are so valuable is beyond me. Maybe the income of some specialists should be reduced....or at the very least, maybe there should be some real competition and real financial openness injected into our care system....so that there is a sense of accountability in billing. Something needs to change...
My family BCBS health insurance (I'm a solo rural FP) is now $1400 per month! For a $5000 deductible plan....no eye, no dental, no pharmacy. We barely ever use it. Do the math. This is outrageous....and there's no stabilization in sight.
Physicians need to consider themselves as not only part of the fix....but as part of the problem as well. We are not free of involvement or causal relationship. It's not solely everyone else's fault.
Insurance companies and the government spends its time trying to figure out how to pay us less and demand more (like EHR). They are protected and immune to anti-trust and can collude at will. We can't.
Business school or not.... Who do you think is going to win ?
D.
If you contact me privately, I'll be happy to share specifics.
2) So at present we have the following situation.
doctor--> third party--> patient
You are proposing:
doctor--> Athena--> third party--> patient.
I have a better solution
doctor ---> patient
followed by ,
patient----insurance.
Get the third parties out of the doctor-patient interaction altogether.
Just my third-party free two cents..
My wife's cousin designs software for Apple. We have had extensive converstions about this topic. His conclusion...the current federal government mandates and the current coding system are roadblocks to the development of a physician friendly EMR.
I agree.
EMR: great, if it can make billing more efficient, simple, and accurate. Must require less time not more. However, when it comes to the nuances of diagnosis and management it fails completely.
You must have this monthly and meet with your practice group to go over these with a fine tooth comb. You must review each and every rejection as many are bogus. The insurance companies goal is to take your patient's premium money and keep it. The more excuses they can find to hold onto it, the better for them.
This is a battle in every practice...sad, but true. None of us should be afraid to fight for what we deserve for the services that we provide.
If a doctor can find out what other doctors have done in their offices/clinics, the results of all labs and x-rays and hospital admissions, then it can be helpful, save time in tracking things down, save costs by not repeating things and improve quality as patients do not always remember or tell the "whole truth" about their history.
Throw in pharmacies so can see if the daily medicine prescribed is being filled as needed, doctor shopping and drug seekers and it becomes even more valuable.
Something is going to be needed with the initial costs and upkeep .... though may be able to save employee time, and overhead, by being easier to get more information about the patient.
Also, if have access when at home and on-call can help with that too.
The problem with this type of access, is security from hackers looking for this information.
the ideal is stil patent pays doc and then works out with insurance co.. and the best was always that patient HAD to PAY a PERCENT of bill.. therefore they discussed and decided and helped controll costs.. ie they actually might really work at PT before expensive tests.. after my own shoulder surgery i watched the dynamics in a PT dept of hospital.. even those OFF work for short term disability DID NOT FIND TIME TO DO PT to help themselves... why ?:? NO FINANCIAL repercussions! they did not appreciate the expensive care they got for minimal invest..
My Kid recently has been around to diff med schools and training programs in Sr year.. HUGE inefficiencies where there is NO Electronic medical records.. constant battle to get results. and slower... having said that,, i think the electronic advantages are being used AGAINST US.. when the system gets too complicated it is used to PAY US LESS rather than care about our care of patients being more efficient..
We need balance billing.
So, what's the answer...elimininate Medicare/Medicaid, privatize Soc. Security, death panels, rationing of HC, no care for illegals, age 80 for Medicare eligibility, Tort reform, Insurance Reform, more MD cuts, stop STIMULUS/TARP/CLUNKER spending, more expensive EMRS, HSA's, permanent lower debt ceiling, 70% tax rate across the Board, or Revolution, etc.???
Take your pick (s), we can't have it all and survive. We can't have it all.
The system I am in right now, is shared by 4 to 5 major city hospitals and so I am able to read specialist notes from cross town, or look up any lab admission etc
It is much better than waiting for the typed consultation letter, instant, typed radiologist results instant. I can send of letters to patient while I am at home and know when patients open then up and read them!
I like the fact that patients can look at their own labs them selves.
I am all for electronic medical records and I think they make our work easier if designed properly.
We shouldnt be fighting against this, we shold be fighting for tort reform and the fact the insurance companies dictate to us, when to screen and how to screen otherwise we get dinged without giving the patient any insentive or responsibility to make sure their BMI's are normal, their BP's are under control etc.
We have been put in the middle between the pateints and the payer and that is what we should focus on as physicians and that is what is killing us as a profession!
What do I think would improve the
Where else in the economy do people eat at a restaurant but the restaurant owner has to fight the credit card company to get paid?
I disagree. This statement isolates physicians' financial fate from that of the rest of the health care system, the patients and the country. This is a poor way to look for solutions to our problems, which are inextricably linked to others'. It also isolates us politically, when we need more allies than ever. And, while a certain degree of financial security is necessary, and should be obtainable in a way that leaves docs a little time to actually see patients, it is not equivalent to our profession's survival or demise.
It reminds me of g.i. endoscopy 30 years ago. When we were just looking at the stomach no reduction in patient mortality occurred . When electrocautery was introduced and ulcer bleeding could be stopped mortality and morbidity plummeted. The analogy is clear,when you simply document something it does not get rid of the problem nor should one expect an improvement in morbidity or mortality of any significance. Moreover do these potential vast expenditures by the medical community give enough bang for the buck?
On the practical side of electronic billing the best thing I did in my practice was having a professional billing company do all the billing. This got rid of of constant billing employee retraining ,sloppiness and non followup of refused procedures and equipment updates. For four or five% of gross billing I got rid of a lot of headaches.
EMR and EHR are similar terms pertaining to different scales as they are used now. The EMR is the medical record, in electronic form, for one patient while the EHR is the aggregate form of that record. These are not hard and fast definitions, but they do seem to be the evolutionary direction in which the industry is headed. Both terms, though, at least theoretically relate to systems intended to capture information about a patient's state of health and the medical interventions used to optimize that state.
Billing systems, on the other hand, can be but are not necessarily related to health records and, in my opinion, should not be. Billing systems have the potential to increase the efficiency of practice finances, but they cannot improve them per se except to the extent that, within the current third party payor system, they can allow upcoding. This can only occur within the context of integrating billing into the EMR, and this approach will always be a money loser for the individual physician or small practice.
The insurers have the willingness and the resources to change billing criteria at their whim, and the individual physician cannot afford to re-jigger his or her billing system and EMR simultaneously each time the insurer does so. Yet this is what would be required for a billing system to offer improved finances to the practice. The current uproar over CMS's Meaningful Use criteria offers a perfect example of this. CMS is dangling a carrot - up to $44k per "eligible physician" - to physicians in order to get them to "upgrade" to EMRs, but the requirements for meeting the necessary criteria are not yet well defined, and there is considerable and contentious debate in the IT community over what rules should be defined and at what time. And integrated billing is an assumed but completely separate (and undefined) part of that equation.
The bottom line is that the regulatory environment has become so complex that medical billing is beginning to collapse under their weight. Making a substantial investment in the technologies necessary to join the game is a huge financial risk, at best, taken for little gain (a reduction in the costs necessary to join is the best possible outcome...) Once the investment is made, the ongoing costs will, beyond any doubt, exceed the initial investment, but with no additional gain. And after that investment is made, the physician is essentially "locked in", with no chance to exit other than to scrap the entire system at once and alter the basic economic format of the practice. There exists the possibility of the avoidance of future, as yet undefined, payment reductions, but only if all the as yet undefined criteria are met within the as yet undefined deadlines, and with both the criteria and deadlines variable according to both the political desires of CMS and the economic desires of the insurers, there is almost no chance for a meaningful long term improvement in practice finances.
If health care was a free market, then billing efficiencies could be expected to translate into increased profits. With the price controls imposed by CMS, however, and given the current and potential complexities of attempting to implement billing systems, the costs of doing so almost certainly cannot be recouped. Any increase in billing costs will translate to reduced practice profits.
The only sensible course is to eliminate insurance contracting from the equation and, once the practice has re-stabilized, begin at that point to take steps to reduce billing costs (and only billing costs, unrelated to the EMR) as far as possible. At the same time, steps could be taken at that point to implement EMR strategies which can reduce practice overhead and improve patient care by reducing record storage costs, increasing the speed and geographic locations at which records are available, and maintaining clear, concise summaries of historical patient interactions.
The ultimate promise of the EMR is secure, rapid, widespread availability of patient care data. GE's TV commercials during the Olympics have illustrated that point very clearly. By using the EMR primarily as a tool for gathering billing data, however, the current third party payment system has suborned that notion to the extent that it becomes economically non-viable for small practices. It remains to be seen whether that lack of viability will also be the case in large systems.
BUT HERE IS WHAT I NEED -
For a simple low risk visit, my handwritten scrawl of "Sinusitis - Ceftin 500 bid x 10d" should suffice. I shouldn't have to document at what age the guy's grandfather died of a stroke to get paid my level 3!!!!!!
ONE OF THE MAJOR THINGS KILLING THE PHYSICIANS IS THE OVERHEAD. We are the draft horse in the traces hauling the cart with an ever-increasing cadre of administrators and transcriptionists and coders and auditors to meet a mind-boggling array of ever-increasing regulatory hassles.
We need to stop playing that game.
They want to enforce a system-wide EMR to audit us and pay us less - not because it'll help us or the patients.
better documentation and increased support for 99215 ... Oh, we've stopped paying for that, we now pay the same as a 99214
Oh, we stopped paying consult codes, we now just pay normal office visit codes.
Sermo Doc 38 has it exactly right - a quick note that contains appropriate info is what is needed, not a 10 page EMR note noting every little bit of family history and ROS which in reality were not done. i'm telling you the next big wave of lawsuits is going to be over little notes in EMR that are damming and not followed up on.
The answer is not to find better ways of jumping through their hoops, the answer is to stop jumping at all.
Be a cat who looks at them like "you're stupid if you think I'm jumping through there" rather than a dumb dog happy for a little doggie treat at the end of the day.
2] athenanet lets you know just what third party payers are doing to screw you
3] E+M codes, even on paper, are the #1 time waster for MDs
4] better to have no intermediary between patient and doctor - medical debit cards - third party payer reimburses patient - then you do not need snoopware as you are not getting screwed - document only what is needed to provide the care to the patient - three visits on one piece of paper remember those days?
Agree fully with Sermo Doc 43. Don't put glitter and tinsel on the hoop.
I could not have said it better! Good to know there is at least one physician out there who thinks of the patient first, and $$$$ after.
as i said before.. Before Medicare ran out of money in 1990 by its OWN FAULT and then started PRICE FIXING DOCS, we had easier systems.. that did not require so much extra documentation..
Polticians claim there is so much FRAUD and they must believe that they can find it by excessive coding and charting requirements.. IN FACT , for the majority of HONEST DOCS who are just trying to TAKE care of Patients and earn an honest living,, this will be USED against them that they did NO CROSS their Ts and DOT their I (eye)s.
they obvioulsy were able to investigate the rare fraud when the codes were simple..
SO, the expansion to Insane documentation and Detail is ONLY to make a game to DENY payment.
Given the adamantine & well-nigh invincible resistance of the Trial Lawyers & Consumer Lobbies to Tort Reform, then perhaps it is time to seek 'balance' by MDs proposing (demanding/litigating for) fee schedules similar to those of trial lawyers based upon 14th Amendment protections, filed by , say, a Big Insider Organization like the otherwise much-maligned AMA? Altho' I doubt that, in such a hypothetical scenario, MDs would ever see much (if any) additional $, it is possible that a useful debate regarding med-mal/tort reform nat'l agenda might emerge.
Thoughts anyone?
Is there a pattern here?
Will TERM LIMITS for everyone in Congress solve any of this?
To me the answers are simple and havebeen stated: Remove third party from the equation and make the patient responsible.
Basing reimbursment on "documentation of a thorough ROS" is utter BS and is just a way for third parties to interefere wtith the true value of what physicians do.
Remove defensive medicine fromt he equation: Being forced to document every little thing for fear of being sued is a large part of most practices as is ordering unnecessary tests to "cover my ass".
I agree taht most physicians do not understand the business side of medicine, however although we are "small businesses" were are not in it for the business. All of us have compassion for our patients which comes first. Without that compassion the third party insurance fiasco and Medicare issues would not be issues because no business would have accepted those terms from another company.
When what we do is paid at a reasonable rate wihtout interference from outside sources or without fear of repercussions of litigation for a known risk of a procedure then we can all practice the great art of medicine again and everyone will be better off for it. When compassion, knowledge and experience are used patients will have better outcomes, at less cost and more peple will be able to be taken care of.
As far as EMR, a web based program that is linked to a smart card that each patient has on them and is inserted into a card reader at each office/hospital so that all old inforamtion can be read and all new inforamtion added to it is the answer...this is portable and secure because the information is only stored on the card. Also documentation should not be linked to reimbursement.
Enough ranting-I leave with an interpretation of the three laws of thermodynamics:
1-Things are getting worse.
2-Things will continue to get worse before they get better.
3-Who says they will ever get better?
Anyway, I also want to say that I don't think many docs who choose to be employed think that is easier. I choose to stay employed because my husband has to move every couple of years for his job, so I have to stay mobile (it's actually a pain the booty). Also, don't think that those employers don't make us employees justify our salary. There is just as big of a push to be well versed in coding and compliance with a large corporation as there is with your own practice, and yes, it's irritating to see how much I make them and how little they pay me, but then again, malpractice is a little easier in this situation than on my own and there's no tail. And that's important when you move a lot. We all have the same things at stake here, employed or self-employed. I wish we could all find some common ground and stick up for ourselves over these issues.
CCHIT will be sole health IT certifier, for now
By Mary Mosquera
Friday, August 14, 2009
The federal Health IT Policy Committee today endorsed recommendations that would leave the Certification Commission for Health IT in the short term as the sole organization authorized to certify health IT systems that qualified for funding under the economic stimulus plan. More certifying organizations would be added later.
Certification of electronic health record systems that met federal criteria for "meaningful use" of health IT could start as early as October, members of the Department of Health and Human Services' Health IT Policy Committee said at the August 14th meeting.
Under the plan, CCHIT would provide a preliminary stamp of approval that health IT systems were HHS-qualified or certified until a final meaningful use regulation is published at the end of the year, said Marc Probst, chief information office of Intermountain Healthcare and co-chairman of the Committee's certification work group.
Preliminary certification is meant to give providers and vendors enough certainty to proceed with planning, designing and purchasing systems in 2010. The HHS certification-qualification would mean that a provider purchasing the systems would be eligible for Medicare and Medicaid incentive payments under the stimulus law beginning in 2011.
Once meaningful use is finalized in December, national health IT coordinator Dr. David Blumenthal could determine how many additional certification groups could be set-up, Probst said. The national health IT coordinator's office would create a process to select other groups with assistance from the National Institute for Standards and Technology.
Blumenthal was positive about the proposal. "I think the workgroup has given us a very thoughtful and workable solution," he said. His office will review the transition plan.
In an Aug. 11 letter to the workgroup, CCHIT provided details tabout preliminary certification. Under the plan, CCHIT will certify some individual health IT components, such as electronic prescribing, for providers who do not have a comprehensive electronic health record system, it wrote. CCHIT would continue to certify comprehensive EHR systems as well.
A fair amount of meaningful use criteria is already part of existing certification requirements, Probst noted. "We now have all the details to put this preliminary plan in place," he told the Committee. It will be submitted (to the Office of the National Coordinator for Health IT) so starting in October we can start doing testing for HHS certification or qualification," Probst said.
Overall, certification should focus on meaningful use at a high level and leave the specifics to the healthcare provider, Probst said.
"We're not trying to say how the systems will work," he said. For example, the criteria require that providers' systems be capable of alerts for drug-drug interaction but not how the software should work. "We need to move into second gear beyond harmonizing standards," Probst said.
For electronic health record systems that were certified in 2008, vendors and providers would only have to update certification for criteria that is different with meaningful use, or gap criteria, such as a privacy review.
IN MY SIMPLE THINKING & ASKING, WHY CAN'T C.C.H.I.T. FORMAT THE E.H.R. FOR ALL PHYSICIANS, FOR UNIFORMITY & ECONOMIC REASONS?? As a dolo practitioner, I cannot really afford it and the government does not have to pay $44,000 per physician starting 2011 IF THEIR E.H.R. WILL BE CERTIFIED!!
Perhaps the Sanest and SIMPLEST is to FORCE THEM to HOURLY US.. then we can establish that this is unrealistic given our MANY MORE YEARS OF COSTLY EDUCATION than Lawyers.. but stil needs to be with patient with skin in the game.. because if they have to PAY too they will become better more effecient patients
Your for Better Healthcare,
Dan Jones, MD
www.JonesPlan.BlogSpot.com
Why the F should I need spend hours everyday to learn and follow a CPT coding - billing - collection process that adds very little to the patient care????????????
We need to find ways to dismantle this system, not give it more power.
New model of practice:
Pt comes.
Pt pays.
You provide care.
You write a note that is more of a medical note than of a bean-counting gimmick.
You go home.
Period.
Praying for 21% cut.
take for instance NY state is highest in nation in taxes and a major Brain and Economic drain is occuring with Rush Limbaugh and Golisono (Paychecks co ) the loudest... rest are doing quietly.
if you join up on the
www.onlinetaxrevolt.com
march to washington dc for april 15 by computer you will see major states trying to do something about this..
NY state and CALifornia are CLUELESS.. in NY state there are only TWO of us standing.. this entire period since started... Michael Regan part of this..
i am watchiing people regularly be taxed out of home and no one still seems to get upset .. and DO anything..
yes the 21% cut can do for DOCS what Large Increases in Cigarette tax does... get some to make progress... Unfortunately many of the new docs have no experience to understand what is going on as often they are salaried and have never seen the actual insane billing reimbursement or challenges.. THEY will , instead, experience JOB termination,, VERY SAD as the "employers" keep cutting costs ....
i am hoping they will wake up and help effect change that helps reimburse them properly for their cost of ed... Here too is a problem.. those whose parents did not earn much probably have no debt and could care less what their fellow classmates are going thru.. I do hope i am wrong here... but in college town here ,, very few kids actually know what their debt is and do NOT know if other classmates have any debt.. THEY DO NOT TALK about it.; some are embarrassed to talk about it too.
1. EMR/EHR (nobody has given me a convincing explanation on how they differ)
2. Billing (lots of vendors out there from mom and pop operations to pretty sophisticated)
3. Strength-In-Numbers (Athena calls this a rules engine, part of their AthenaCollector)
We are going to try and tease out all of these components in a series of grand rounds topics over the next few weeks. There are also some really unexpected findings from the PSI (Physician Sentiment Index) that Sermo & Athena will be releasing (turns out that physicians are MUCH more optimistic about EMRs than one might expect). My sense is that 1 & 2 tend to be confused quite a bit and they likely to have less opportunity to impact the financial health of a physician practice than 3 (rules engine).
Daniel Palestrant, MD
Founder & CEO
Sermo, Inc.
There is a complaint, an issue or a problem with EMR about once an hour.
It is like purgatory.
Lantus cash pay at Walmart $103
Charge to insurance at Walmart $160
45% cost saving just by letting free markets work!
I am a little surprised by the tone of this letter. This is a prosfession we all signed up for. The financial rewards may decline over the next few years, but for me me at least that has very little influence on why I do what I do.
And have any of you talked to your friends with MBA's about how well their doing? I have two goof friends, MBA business types, both very bright, but the bottom has fallen out of their industries (one in tourism, one in high end sporting gear), and both of have lost their jobs with poor prospects.
People are not going to stop getting sick (nor, for that matter, making themselves sick), and our unique set of skills will ALWAYS be in demand. Stop feeling sorry for yoruselves and start remembering why it is you became a physician in the first place.
Now,
how do I go cash only when there is a competitor FP right across the street who has been here longer, has more patients, uses mid-levels, & he is not going to go all cash?
I will simply lose most of my patients, unless I cut me fee down to what they already pay in co-Pays.
I want to scrap those health insurers.....but (aside from already not taking new medicare, tricare, or ANY medicaid) how can I realistically do this?
1. Patient pays directly at time of service- cash, credit card, or money order. Patient provided with printout of information needed to file an insurance claim. (If EHR can do this for us, it may be a worthwhile investment.
2. Patient files for reimbusement with insurance company. If he needs more infor or help from doctor's office, this is an extra billable charge to the patient.
3. With third-party payers out of the loop, office staff can be reduced, and charges to patient can be decreased.
4. Doctors should then post their fees in the office and online. Competition returns, and fees will decrease overall. Yet profits will still increase. I read about an FP who has done this, runs his office with one PA and one office assistant, has more patients than he can handle without expanding, and makes 2-3 times more than the average for FP's. It can be done! Hassles will be reduced, and medicine will become more fun.
5. Specialists like me will, however, have to get used to more reasonable fees, and still make a very good living, but not have the money to be on all the philanthropic boards, donatebig bucks and hobnob with the politicos, have 6 expensive cars in the family, etc.
The bottom line is that medicine will again become primarily a patient-doctor interaction, and less time will be required for the business of medicine. And if the bigwigs want you to have an EHR, let THEM provide you with one!
This will, of course, subject those who take it on to a temporary drop in income, until their new practice mode and patient base are established. If you're living up to the last dollar of your income, cut back & start saving for it. If you have a nest egg, now's the time to use it to tide you over. Your independence is worth it!
Thanx, but I agree with ohioobgyn and how to achieve this ?...agree with Doctor SH.
That aside, I am not sure about the difference between EMR/EHR but, my gut tells me that the EMR is the legal medical record that we create and the EHR is what patients are doing but not telling you about...ie.alternative medicine. Billing...separate issue...pick the clearinghouse that doesn't go down frequently. Strength in numbers...again...agree with ohioobgyn and Sermo Doc 19...
God Speed
The only way an EMR will work is if the process of accurate data entry is closely knit into the office workflow( Dan, EHR is where a patient can also input data...I have never found it that useful as a good amount of such "data" has to be "scrubbed"...
The least painful and most efficient way of record keeping is to ask patient to keep a file folder and instruct them to file only the very vital information in that file ( No filing of ED and Hospital discharge instructions and 20 page EMR generated trash about "what are the causes of abdominal pain")..In India we used to write clinical history in few lines, list meds and problems accurately on the back of used paper/ handbills( carefully cut into 1/4 size to save money... and the poor illiterate patients would guard this like gold, get appropriate care no matter where they went for treatment. In the US, I send a complete secured digital medical record as a compressed pdf file to patient's e.mail or on flash disk.
Unless there is universal patient directed secure connectivity between all labs, hospitals and imaging centers, the cost spiral will NOT stop. EMRs will make life more complicated.
All said and done companies like Athena can be an asset to small practices as they bring the benefit of well-managed back-office operations for the cost of a good employee. The nice thing is you pay for what you use. Allows doctors to take off more often and avoid burnout .
visit IMP group and you will have your answer
you will also get convinced:
1- high volume practice is not good
2- 10 ladies moving paper around in our office and doctor sending pt to every specialist and test known is not what practice of medicine should be
Don't you forget my favorite websites:
Extormity.com and
Seedie.org
Ref : other comments here - yes Balance Billing would set us free, but our politician slave Sermo Doc 26s are never going to "allow" that - the only other option is joint negotiation or cash only.
Ref : doing forms, refills, non visit care for free, simple answer DON'T I charge for all these or require a visit if it is not allowed If the patient doens't like it they are told to go elsewhere.
Sermo Doc 19 nailed it, succinctly
BTW, EPIC sucks big time, the most disbelievable mish mash info generating time draining GIGO
I also work in a big group that pushes the insurances to pay for what we do. It keeps track for us.
Therefore, I'm not interested in paying for extra confusing and expensive services by Athena.
Health care money should go toward patient care. End of story.
We're now in the age of bloated and expensive systems that are more to the benefit of the payors and regulators than to the practicing doc.
The reality of the situation is that doctors are being asked to participate in a financial system as though they are in a free market system when in fact, 3rd party payor systems are NOT A FREE MARKET. Don't cloud the waters here. The only way "business" can ever make sense is with the following. Doctor charges patient, patient pays doctor. Anything else is a perversion of free market.
So either socialize the whole dang system or make it so the patient is responsible for reimbursement from the insurance company not the doctor.
The cost of medicine is going up at an alarming rate because of only one reason. Free markets are not in effect. The attitude is always and I mean always, when it is coming out of someone elses pocket it doesn't matter how much it costs when it comes out of your own pocket you better believe it matters.
These are the simple truths of business.
How do I know these things, I've been in private practice for almost 4 years now and will soon no longer be in private practice because of the inequality of costs vs. payments.
Also doctors fool themselves everyday when they think the public really gives a rip about us and particularly our income. The public thinks we're all rich son of guns and deserve a pay cut, so don't ever look to them for help. So your desire to publicize your pole on physicians will only work to ostricise us even more.
Im not going to say the name as Im not promoting anything...but if you are interested search it. It is working well for some higher volume type offices. I dont have it yet...so I cant say...but it makes a lot of sense.
The idea is to NOT change the way you work and document. Still write your chart paperwork...BUT scan it all in and it is sorted to the correct section (notes, surgery paperwork, authorizations, billing info, consents, tests, etc etc)...
So you get all the positives as far as
(1) Never lose charts
(2) everything is available and in order all the time
(3) Do anything on the computer related to charting that is easy and comfortable for you
(4) Scan everything else.
(5) Get rid of ALL the paper, but on your own time and scheudule...You dont have to be afraid of an implementation date where you cant do things the old way. You can keep the paper chart if you like.
(6) Do your own coding...(how can a computer possibly code correctly?) Coding has too many subjective elements....like complexity..
(7) Patients can use pen and paper and you scan it in.
(8) Nothing highly complex to teach staff vs traditional emr
No interfaces with other equipement needed, but can be done...
Can interface with Eprescribe..etc
This way, you dont have to change the way you work..there is NO WAY clicking on a screen is good for pt care....and it absolutely puts out garbage over and over and repeats errors in a very dangerous way.
Instead read your note (ok it doesnt fix your handwriting, but that is a small price to pay)....
think about that concept....very interesting to me. Just looking at it.
The problem with EMR is that it is trying to make you work in the computer work...
Perhaps a separate thread could be started to expand on the development of a viable third-party-free practice model? I would be very interested in this.
You should get it only if it will actually help you and is right for you and affordable to your practice.
Expecting the bonus is going to be like "Waiting for Godot." What kind of business would actually operate that way...hoping to get paid if they meet nebulous and every changing rules...
its outrageous.
I hope your comments are just out of frustration. Why pick on us specialists who might charge more than you? Why pick us out as the villains when we have a government and society full of financial fraud? So your doctor charged more than you thought it was worth I guess?? Was it really that easy or was the doctor skilled and made it easy for you?
How much did your insurance actually pay the doctor? Blue cross is usually a poor payor. Why were the services not wroth the cost? Compared to the cost of what? The average worker (Im not kidding, this is the actual average including everyone from janitor to CEO) at Goldman Sachs made $500,000 net this year. Our government seems to feel very strongly that they are worth it as they keep supporting that and other similar companies with handouts, easy money via handing them treasury business (like bond sales) on a plate.
If the guy fixed your muscle in a few minutes and it worked and you were healed...what is your beef with that...? Do you think some people in society should have a fixed income while others do not?
I think its always a mistake to polarize our profession. This makes us weaker.
Im not wanting to start a flame war, but I will say that I feel people in your field are overworked and underpaid and I support increases to payments to physicians who practice general medicine and pediatrics.
I don't feel that has anything to do with specialists, however...
Its about as different as the cost of gas. It has nothing to do with what you are paid and we should insist that there is not some imaginary fixed "pool" on money for all doctors....where gain to one means taking from another....
Nothing else in society works this way...certainly not in government.
Imagine if there was a fixed pool of money for military (it goes up all the time)...or for government workers salary and pension (it goes up all the time)....or for bailing out zombie companies (seems unlimited)...
Im not going to stand for this concept when the rest of government spending is limitless.
Doctors are paid a very small fraction of healthcare dollars. Lawyers may even take a similar percentage of total healthcare dollars! No one knows.
So tell us what your insurance company really paid your surgeon for your procedure...and stop blaming your premium on doctors...
You are dead wrong. Your premium goes up because our society does not know when to stop consuming. Healthcare, houses, junk from China in WalMart.
Since there are no limits to consumption, costs will rise forever and there will never be enough resources until the day everyone in the country works all day providing heathcare for everyone else.
Your case was cut and dried. You had a problem, it was fixed.
How much...not the charge...what is the allowed amount?
Where were you seen....ER...office?
Did the cost include only the doctors time, or also office space, staff, suppies.
Does the procedure include 90 days followup?
Lets see?
NO ONE CARES MORE ABOUT YOUR MONEY THAN YOU!!! No excuses to not know how you get paid. No excuses not to understand the basics of a profit and loss statement, balance sheet, and cash flow requirements. My god people, how do you balance your checkbooks?? Seriously, by an investing book on how to evaluate a company. It will explain what to look for in those items. You need to know the basics or you won't know what dumb questions to ask the accountant and you are at a high risk for embezzlement.
They make deals and settlements and sometimes end up getting less money than they were planning but they get it. They charge for their time and knowledge.
Why don't we learn and get rid of all the 3rd party BS and all the regulation, etc.. instead of hoping that more technology will help us.
EMR is like pornography, in the old days we looked at a magazine, now is on a computer monitor, but it's still pornography. Technology just made it more accessible... but it's still "bad for you". Just like the TelePrompTer did not make Obama a better president.
So we'll still get screwed (electronically) with EMR/EHR.
Patients cannot keep track of medications no matter how hard we try to get them to keep a list. One pharmacy does not know what another has given to a patient which leads patients to use more than one pharmacy and sometimes in those that are in early dementia or just ignorant take extra meds. There is more tracking of behind the counter SUDAFED than there is HYDROCODONE yet hydrocodone still outpaces meth in terms of usage. Link pharmacy data to each other and to our EMR - surescripts is actually trying to do this now which so far is not turning out to be that good but it is heading in the right direction.
If the government wants to force EMRs down our throat, then make them on some sort of standard platform that promotes their communication but not create one of their own like CPRS (although it really is not a bad system compared to others). I don't care if there are more than one EMR vendors, in fact i welcome i as competition breeds improvements, if there was no Apple and Linux, Windows would still be running like their millenium edition :0
Want to keep third party payers? Then they have to accept efiled fee tickets from the EMR. For those who argue that computers cannot determine the complexity of an office visit, I agree, but neither can certified medical coders that review charts, they are not doctors, and they are the ones that review charts at the insurance companies or are employed by large groups to do the billing.. Our EMR has an overide button that you can put in the level of service yourself and not let the EMR generate it. You should be able to generate a list then from your emr of outstanding bills much the same way a paypal account works. Once you purchase something it is shipped and the little package light comes on, the little $ sign lights up after you pay for it, then you leave feedback by clickng the thought bubble. Why can't we send the bill and when the insurance company processes it and sends us the money, it lights up the paid button. This can/will work if someone puts their mind to it, there are much more complex computer programs out there.
What else... oh in terms of althena, i have no opinion on that because I think the problem with the way billing is done needs to be fixed and not adding another person/layer to pay to get my money for me, we already employ/pay too many people to do that already. it should be as simple as submit bill, get paid.
2) The electronic system can have huge savings of time if all are linked to it.. specialists, radiology, lab, pathology etc... Like the VA has had for. what, 30 years??? And we privates still have nothing like it..
3) As so many have said,, this is a moving and unfair game... no matter WHAT you do to jump through all their hoops, the rules will be changed to benefit the insurance CEO's and their stock holders... and diminish your autonomy and income...
4) Bail out!! Cash if you can... This code nonsense is destroying us... timewise, morality wise with the gamers of the system etc..
5) A wise physician-colleague told me 20 years ago that the social contract between American physicians and society had been broken.. We would give the best years of our lives to amass a large data base of information and techniques, and in return, we would be paid well and have an opportunity to help our fellow citizens in very meaningful ways... For me, over the last 15 years, it has not been the income issue, it has been the loss of liberty/control.. having to justify my prescriptions, radiology requests and referrals to a bunch of illiterate, ignorant reviewers has taken the fun out of the game!!
Good luck to you all - those who remain that is..
Could not agree with this more.
If Athena--or anyone else like it--wanted to be helpful to us, it would become a service to PATIENTS to help them submit charges to their insurance, because quite frankly, that's a business we want out of. Pronto.
I think it was Firedoc1 who came up with the new definition of single payor--the new "single payor" is the patient; they pay us directly, preferably in cash--although, I suppose credit cards work just as well.
The EMR record arrives, informing me in great detail about his ROS and in his exam that he had no nipple discharge and a normal breast exam. Comforted by this info, I tried to determine just what was wrong with his hand. Contusion and LROM, pain. Radiographs were ordered but the record did not indicate an official reading despite a diagnosis of metacarpal fracture. No mention in the treatment portion of the record of any bracing or casting, nor of any followup or referral for care.
There's your EMR. No nipple discharge, but inadequate documentation of the actual injury, imaging, and treatment. I can't remember the last time I checked for nipple discharge with a patient with an injured hand with contusion and fracture after a fight.
And I still don't know which metacarpal was fractured.
My impressions of EMRs - patient records should be maintained on regional database servers accessible by any doc with proper clearance with an individual patient identifier number via a computer with DSL access to the Internet. The EMR should be maintained by the beneficiaries - the Feds, States, and insurance companies - on their dime, not mine. I see the patient, access the record, record my exam, orders, review all imaging , lab tests, and pharmaceutical records as well as specialist referral visits from central data base. The Feds and insurance companies can afford a crack IT team to maintain the universal EMR and the headaches associated with security and other tech issues. I cannot. My solution solves the problem of interoperability of systems and health exchanges. Why reinvent the wheel? We have an interoperable system called the Internet.
1.Hope Sermo is not out to "endorse" Athena; I value Sermo's independence, and got interested when you exposed the AMA for the corrupt bunch of lobbysists we always thought they were.
2. Difference between EHR and EMR: EHR can be patient founded/maintained, at sites such as Google. Whether the patient bringing in this printout is helpful is dubious.
3. From a Grand Rounds at our hospital: Implementation of a full EMR can cost 1/4 million $ and up, and will decrease the number of patients seen (and with it productivity) on average 25-50% in the first year. Many vendors recommend just closing your practice for 1-2 weeks to "adjust" to the new EMR. Dan, I may not know the exact definition of cash flow, but I do know these numbers are unacceptable.
4. Agree that the Fed Stimulus money is a joke. No system has yet been certified, HHS took forever just to publish general criteria, and I think their (the government) ultimate goal is to get inside your office and be able to search through your records at their whim.
5. There are simpler/cheaper ways to just digitalize your current charts and maintain current practice routines.
6. Am also looking at various "supergroup" type arrangements; perhaps that may be the best way to somewhat stand up to the insurance companies. Perhaps you could report on the different options and experiences with these arrangements.
My state society meeting was last week . Our lobbyist made it very clear to us that the politicians do not care about physician incomes .
The politicians only listen and notice the PACT contributors .
My daughter recently had surgery . A week prior to her surgery , the doctor's office asked for her credit card authorization to bill the balance of her surgery bill . The morning of surgery the hospital estimated and billed my credit card for her hospital
bill . An OB GYN I know now asks the patient at time of visit to authorize credit card for any services not covered by patient's insurance.
Great post and solution that already exists!
Good comment and I agree.
Can you give us more info on the ' various "supergroup" type arrangements'??
Thank you.
The only way to regain control is to go back to fee-for-service.
Then your customers/consumers/clients will go back to being patients and you will be a physician again and not a provider.
Presently we have no control over our expenses or our fees.
At least wirh control of our fees we can raise or lower them as costs change.
In turn out patients can then put pressure on the insurance industry/lawyers/politicians/government to help control the costs to physician of providing medical care.
Right now the physicians are the "monkeys in the middle" with all control bypassing them.
Do I think this will happen? Nope. Doctors will never agree on anything.
And to those ideologues who are going to tell me about "The Oath" I took........
Get a life it is nothing more than an ethical guideline and ceremonial in nature.
It also isn't taken by all physicians and there are different versions.
So don't bother with that worthless "pap".
Short sweet and to the point...and right on....
We are kidding ourselves if we think we can get ahead of the govt and the insurance companies.
Better come up with a better mousetrap than what we have now.....
" Here's your sign" So you are a doctor? " Stupid"
Yup I got one too....
I am against the EMRs. For our small practice already in debt, the cost is horrific.
we have exellent templates my husband designed and our notes are clear computer printouts. I simply do not have the cerebral connections to stare into a computer or scratch things on a hand held while concentrating on my patient. My programming does not work like that.
I need to look at my patient, connect with his/.her eyes, gestures, grimaces to get a really good history. I need to concentrate on my p;atient. Have had peo;ple say "no" when asked about rectal bleeding, for example, but is is said in such a way (guess it's my theatrical training) that I know I have to pursue that line of questioning. And it turns out, maybe they said no as they don't have it all the time.
With our method, I can make quick little notes on our template and then later add to the notes and print them out. works well for me.
EMRS are not without error. Seen by everyone.
Maybe someone was obese and did not exercise ten years ago, had high blood pressure. Since then lost weight, exercises, BP jnormal without exercise. WTih the EMR, it remains forever. Our records need to be kept for only a certain number of years. I have had this happen and patients penalized.
I could go on and on....but we are leaving at 3AM for Breckenridge....and I will be computerless as we need to conserve weight on the flight.
EMRS are automated and often I get reports from specialists who have them...and things are checked off which are inaccurate...such as "Breasts:normal without mass" on a patient who had a mastectomy and no implant.
another: "Allergies: denies all allergies to any medications." This is a patient who developed STevens-Johnson syndrome after having sulfa.
These things do not happen in our templates. of course, you can attack me for errors...we are not perfect...but we do a pretty good job without EMRS
I think I am screaming. I had better go have a cup of chamomile tea to calm down and then pack so we can leave at 3 AM for the Ft. Lauderdale airport
Now that I got that out of my system, speaking of "systems", it is quite funny to see some of the letters from specialists. They use templates of some sort, with dictation or EMR. For example:
Dear Dr Sermo Doc 75:
I saw your patient, Mrs XXXX, and....etc etc....
Thank you for allowing me to see this most pleasant patient.
Sincerely,
Dr Specialist
The attached H and P indicates that Mrs. XXXX is:
"An overweight female, BMI of 40, who is alert and cooperative, and *smells of urine*."
HEALTH CARE IS NOT A RIGHT!
A Right is freedom of action in a social context. A Right is NOT a license for extortion of benefits from others at the point of a gun or by Government edict, also by force. In a free society the initiation of force is banned. That is why the Founders after enunciation of inalienable rights to life, liberty, property and the pursuit of happiness indicated in the Declaration of Independence: "To secure these [individual] rights, Governments are instituted among men". The Government is vested by the governed with the monopoly on enforcement, but only in retaliation versus criminals and foreign aggressors. All initiation of force by the Government is unconstitutional. - It is clear that the Founding Fathers talked about the only sovereign in America, The Individual.
Our Government at 200 years later is evading its purpose. The protector of individual rights today became the monstrous slave driver intent on eliminating the last remnants of freedom of a once proud profession. - This is the battle that we must fight!
patients call me with no insurance, wishing to pay cash.... And to make it worse, 'our association', the AMA has helped institutionalize medicine with, in particular, procedure codes. Any doc with enough time can load up a visit note with enough irrelevant facts to make all visits a 99214! I think the 'system' has not melted down far enough that people will really get together to fix it!
D.
The problem Athena and all other billing companies are going to face is the rapid nearly 25% decline in physician income starting this year. Traditional 5-7% billing charge is out of question for any reasonable practice. I have done my math. The sweet spot for delivery of high quality billing services is around 3.5-3.8% of he amount collected. This means nearly 50% of the work (f correct coding must be done at point of service using hand held devices capable of reading 3D bar codes off a record.This encoding must include complete demographic info for billing, even perhaps biometric data, verification of benefits even before patient is seen). Unless medical practices can be transformed into a UPS like organization with centralized design of databases, real time data collection and real time charge for services, I don't see much hope both for medical practices and billing companies. The CMS, EMR, Insurance lobby, Pharma all screwed up big time. They missed out on a very unique opportunity for high quality national ID card that could be used for a variety of services including health information exchange. May be we need to outsource this stuff to Nandan Nilenkani! If India can do this why can't the US?
Sermo Doc 82, practices such as yours and others that have diligently designed and implemented systems that work should be congratulated. Most physicians are not tech savvy and will need an intuitive system that may have to be customized for the individual practice, but interfaces easily with anyone who can use a computer.
As we have learned in almost 4 years of a failed attempt, you must pick your vendor well and have excellent local IT support, as well as a willing staff to be successful. We had critical weaknesses in all areas. I have learned a lot. And, we are currently on hold. Our entire in house architecture is based on Windows XP SP3 and we can't move forward without starting over. We scrapped the office EMR system and forced the vendor to refund the entire investment...which they did. We are functioning with a lab system, PAX, digital dictation and a functioning schedular tied to a basic paper record. It works for now.
I'm meeting tomorrow with our regional referral center about a number of topics. One of them is their forced installation of a new Mckesson system that has been thoughtlessly introduced and is failing before it even gets off the ground. The administration didn't do their homework. This is not an isolated occurrence.
Uh, just wanted to say hi.
I hate doing progress notes on EMR. I'd rather check off things and write indecipherable notes on the bottom, really quickly while I'm gazing at the internet. Actually, there are good things and bad, and I like the fact that I don't have to write in a bunch of words explaining how the lymph nodes were. I can mark on a diagram of an unrealistically trim healthy person where the pain is. The infant picture to mark things, like where a rash is, actually made me smile.
There are multiple problems, however with our EMR, which is Epic. The main one is lack of friggin communication between facilities and doctors who don't have our system. Now the big affiliated hospital is hooked up with us, and most of the specialists and their offices, but outside...stupidly no.
So we still have to scan in dozens of labs, ED notes, hospital stays, consult notes into our system daily. We're behind on scanning by over a month now, due to three other doctors here. It's a mess.
As far as payments, I have this very nice but assertive Italian-American lady as a manager who is very open to telling me what a blockhead I am if I continue to see patients on the Doofus Inc. Plan, etc.
I am in a small group practice, Orthopaedic surgery. We have always have an electronic billing and accounting system for patient accounts. We have always done our own billing and current collections. (Grossly delinquent accounts are turned over to a collection agency) Our collection percentage is in line with national averages and our A\R are up to date.
We are using the government stimulus to update our electronic systems to a fully intergrated EMR/billing package. My hope is not that this leads to a pheonix in collection and income, but that after the system is implemented and the templates are all worked out is that our efficiencies improve. I want to write and dictate less. I would like to spend more time devoted to treating patients, and less to dictating letters of appeal for denied claims. It is true that we hope to save over $25,000 dollars yealy in dictation expenses. I am hoping that the EMR will make me a better, more accurate and more efficient physician. Not necessarily a particularly wealthier physician. While I am no champion of healthcare reform (nor healthcare payment reform for that matter), if Mr. Obama through the economic improvement legislation is willing to pay for over 80% of the costs of a fully implemented EMR billing system for my office, then I'm willing to try make it work!
As Sermo Doc 6 said, if there were an intuitive, effective tool available, no one would need to 'push' physicians toward it.
Most - perhaps all - EMR/EHR notes/records I have seen have been an insult to professional medical care. Anti-intellectual would be kind.
I DO believe that computerized records COULD be a boon - professionally and economically. But I do not believe current iterations are.
The current trend of designing EHR to supplicate and facilitate CPT is only likely to enslave healthcare professionals.
Let congress 'demand' that EHRs be designed to 1) intra-operate and 2) FOCUS on the doctor-patient interaction (NOT the CPT-specs of that interaction), and this could have a benefit to patients and doctors.
Thanks for the compliment. Regarding "supergroups" for OBGYN in the Northeast, I know of two- one in CT, one in NJ; I believe each has 80-100 docs who bill under one taxpayer id; that gives some weight in negotiating with insurers; for doing the billing, I think they get roughly 5% of collections; there are also potential reductions in liability insurance and purchasing economies of scale; they try to otherwise let each practice continue as it did before joining, but in some cases have some practice guidelines to follow. Each practice that joins usually controls hiring at their own location. You have to weigh some loss of independence and their commissions versus potential increased reimbursements, other savings, and having to manage less in your own practice. From what I can see, there is even some choice for member providers as to which insurers to accept in network. Again, this might be an interesting topic for Dan to explore. Our group has just started to look into this.
A very well designed interface can GREATLY reduce the number of keystrokes to get the job done. The problem is that it takes a very bright person to merge the science of databases with the knowledge of medicine, workflow, archaic CPT and ICD 9 codes.
It takes a genius to set it up to take less time and effort than a well designed paper template apparently.
That as such has yet to occur. We sadly await the birth of this template designing messiah to liberate us from the evil oppression of the current archaic systems.
If you build it, Docs will come bearing Krispy Kremes by the terabyte!
In a news release, the company said that right now when it receives an implementation fee for its software it only amortizes the payment over a year. Auditors are looking at whether it should be spread out further. A shorter window would have the effect of boosting reported revenue.
Athena is best known for its omnipresent CEO Jonathan Bush, a media darling. The company's business is dry; it sells practice management software to doctors and collects a portion of revenue that it bills insurers. It has recently been recasting itself as an electronic health records company--a hot area ever since the stimulus bill in February included $20 billion in Medicare subsidies for doctors who go digital. The story had been working. Before tonight's drop, the stock traded at a lofty 53 times earnings.
Physicians don't need to be like business people. It is the conversion of the profession from a profession to a business that has brought many woes upon us. We have a heart, with compassion for our 'customers'. Check out such well known business examples as BOA, FNMA, AIG to see what business men are like.
We do, however, need a good grasp of how we earn our living, and we need to remember that we sell knowledge and experience. A certain amount of 'free work' can be tolerated, but too much will bring down a practice.
The public is basically 'average', and is subject to those basest of human emotions, envy and greed. While they like us well enough in our office, they can't wait to decry us at their local beer gathering. The entitllement mentality of the socialists, beginning with Roosevelt and greatly expanded by LBJ's great works, has resulted in the public feeling that all their medical care should be free. We should 'serve' them freely, not in a for-profit mode. It has taken the socialists 60 years, but this country is now 'there' in their thinking. This august body of our populace sees nothing wrong with wasting millions upon millions of dollars on sports figures (with perhaps 3 or 4 years spent learning their skills out of high school), but resents us charging anything at all for our skills learned in 12-18 years after high school. Our younger colleagues' incredible debt load is astounding, but garners no sympathy from the ignorant masses.
This cannot be changed. It is the nature of the beast. As for me, I am getting out soon. Thousands of my generation will take early retirement to escape this. Our profession will continue to deteriorate as the public crushes it with antipathy and indifference in deference to their own collective desires!
I wonder with incredulousness where Obama thinks the extra physicians will come from when everyone has medical insurance and floods the offices and EDs with sniffles and fibromyalgia! Botique medicine, anyone?
EMR / EHR is merely a means of corraling us all together digitally...so that our data can be scrutinized / reviewed / used / managed / and maybe even "paid for", sort of.... It is NOT about patient care, as we are being sold / told. This is a lie. As medical "record" is is very poor....and is fraught with pressures and temptations to act in fraudulent ways. It's used to "build a billing foundation"....to jack up the ability to "code higher"....even if the "checked templates or defaults" were not really all a part of the day's visit. It's hard for doc's to admit this is going on, but we who are honest about its construction and usage know what I am referring to. "Cookie cutter" patient visits are pumped out of EMR / EHR. Enough said.
Doctors need to all reconsider their primary first calling, if you will...and refuse to be sucked into "the business of medicine". It's a great profession that will not always guarantee a "good living". So be it. Sure, we need to fight for fairness. Sure we need to try and clean up the insurance messes and abuse. Sure, we need to try and limit government's involvement and intrusion. Sure, we should try and have input into the debates, but....at the end of the day, we need to be able to look in the mirror and know that we, physicians, have done the best thing for our patients and given our all on their behalf.
Sounds ridiculous to some, I realize, but we must not allow ourselves to be sucked up into the "business of medicine" debate to the point that we loose our ultimate focus. We need to be good stewards of medical resources, be honest and fair in our personal dealings, and care for our patients.
That way, you could look to see what you got paid at the end of each day, the end of each week. When you looked back to see a day where you busted your ?ss, but got paid very little, you could poke around, encounter by encounter to see what you did to NOT get paid.
This would help us understand who and what pays and who and what does not in a format that we can understand.
Absolutely Sermo Doc 15. You are right.
I am in a clinic of many doctors that have started Athena 1 month ago.
I am very computer savay but I am functioning at 50% now. I will eventually get to 60-70 %. But I will never see the patients I used to see. In times of problems of healthcare delivery, why are we being more in-efficient?
Most of us say we see reems of typed words that are meaningless. Our hand written notes are more descriptive and I can remember the patients and their visit very well. I can't remember all those typed words generated by one click of the mouse and I now ignore most of my previous encounters since I don't have time to scroll through screens fo the computer and it does not have meaning to me. I now just see the patient as if a new one or what I can remember. It is sad we have come to this.
The chart becomes reems of meaningless words that are as mindless as the 2000 page healthcare bill before congress.... God help us all.
The problem with making patients submit claims to insurance companies is they can't figure out the maze any better than you can, and they will keep coming back to you to get more "documentation".
And if physicians post their fees, what will stop some doctor from having a "$10" special? We don't need to compete with each other. Doctors already do that, and it has worked against us, because we do not speak to Congress or the attorneys with a uniform voice.
The last thing we need is another layer of complexity with another consultant like Athenahealth. Smacks of the AMA.
We drank the athenahealth koolaid a long time ago. We have convinced a lot of practices to sign up with athenahealth. Athena helps diddly squat.
They and their rules engine are NOT any better than comparable billing systems. Their main focus is on giant practices / CVS redi clinic/ giant urgent care etc.
They are not bad. They are average/mediocre. Their so called rules engine is pretty ignorant even after all these years. At the most basic, it doesn't know when a pre-auth is required and when one isn't. Doesn't know individual medicaid rules even with doezens of practices from that state being in athena (eg: in our state medicaid won't pay for more than one 99239 per patient within a rolling 30 day period)
Just a fricking useless thing for most of the big headaches.
And the implementation is a big pain.
If you are a half decent doc on top of your billing, you don;t need athena and its attendant headaches. If you are too busy to look at your denials, athena won[t help you and might make your situation worse, because if your claim fails athena rules, athena never even submits the claim. It just sits in a bucket waiting for you to fix it.
Lets not market athena please. I realize Sermo needs revenue to run. But athena could be the new CPT, another powerful albatross.
So lets not waste energy on this battle
Is there a way the Sermo community can effects the dictation of the insurance on us?
Can we effect tort reform?
Can we give patients more responsibility for the lifestyle choices instead of penalizing the physicians who kindly accepted them in their practice? (by insurance witholds and P4P)
We are the public as well, not one of us would dream of not buying medical insurance for our selves and family and so right now we are put into a position to accept an inferior product both as consumers and providers.
We don't need to go to business school all we need to know is who butters our bread and which side it is buttered to get to the crux of the matter
I do NO billing and opted-out of all government and insurance programs 12 years ago. Life is good. Taking good care of one patient at a time without any third party hassles restores the doctor-patient relationship, and lets me keep all the money. Practicing Medicine is a joy and priveledge again. My liberty trumps everything.
Re:EMR's are great for playing the "billing game". They are not so good for transmitting essential data to referring physicians that are useful in treating the patient.
I agree!
I used an EMR for a while (stopped when EMR company went bankrupt). I loved it, but IT DID Not SAVE ME TIME in creating the medical record. I've seen the notes of many who say the EMR saves them time. Most such notes are propagated repetitions that tell you little about the uniqueness of that patient visit. The educational value of EMR generated consultations is lost because rarely does the EMR generated note document the consultant's reasons for his/her decision.
I will get another web based EMR when one is affordable again. It does save time on the back end (no looking for charts, no dragging charts home to complete, etc). Nevertheless, unless you are content with "cookie cutter" notes that tell you relatively little unique clinical information (especially with the complex patient) expect to spend more time not less creating most chart notes.
Also, I found the cost was a wash. The start up and maintenance cost were such that I did not save money. Large groups and hospitals may get around some of the cost by having in house IT people.
With respect to EMRs and quality the jury is still out. There have been articles supporting both sides of this issue. Suffice it to say EMRs are capable of contributing to major errors and quality issues. When the errors are due to design issues it has not been settled yet who is at fault (the physician vs. the technical people-new malpractice issues).
I can't tell you how often the EMR notes I receive from inside and outside our practice have absurd contradictions. Retinal detachments with normal fundi, nuclear sclerosis status post phacoemulsification, surgery dates in the future, signatures by doctors who have never seen the patient....
The only good news is that when the system is down and the EMR unavailable, one can't tell the difference, as one has no notes (worth looking at) anyway. Every patient is a new patient, but you can only bill them as established!
And it's slower too, by a lot...
I am NOT HAPPY with sermo getting into bed with a corporation of any sort at this time. Sure if you want to sell them the results of polls, whatever.
But this Athena thing makes me wonder if you are an investor. That's my vibe. Just my feeling about it.
Sermo Doc 78 --- if by ''private practice, you mean solo practice,....do not change and join a group unless you are doing so for other reasons besides $$$. Life is too short to try and find our true satisfaction through monetary gain. Hang in there with private practice...
We are privileged to be physicians and should help one another remember our calling, if you will. To serve others. yes?
I would beg to differ. I started my surgical practice almost 5 years ago with hospital support. In that 5 years I have yet to take home what I took home as a military surgeon. y wife's partner who started an OB practce in the same area took 3-4 years to take any money home.
Physicians may be highly paid but they are usually from specialists in downtown urban areas. Most private practice docs in rural america do not do nearly as well.
Remember also that if physicians start taking cuts we will be forced to layoff employees thereby contributing to unemployment. Charity coerced by government is not charity it is slavery.
Will this change the sermo-athenahealth, inc partnership?