Daily Healthy: financial

Health Care for the Poor

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There are over <a href="http://www.census.gov/prod/2013pubs/p60-245.pdf" target="_blank">16,000,000</a> American children (21.8%) who live in official poverty and <a href="http://www.nccp.org/topics/childpoverty.html" target="_blank">double that number</a> who are just poor. This is not happening in an obscure country, in a continent far away. It is happening right here, across the street from you. For those enjoying a good episode of Duck Dynasty, these are not children of illegal immigrants, and the vast majority is white kids. Over <a href="http://kff.org/other/state-indicator/children-0-18/" target="_blank">44,000,000</a> American children (more than 1 in 3) were served by Medicaid and the Children’s Health Insurance Program (CHIP) in 2012. You can look at these numbers and be proud that we are helping more kids get proper health care, and you can listen carefully and hear the underlying narrative of an America raising its future self in abject poverty. Redirecting your gaze to our health care reforms, you should now understand that American health care is being transformed precisely to service this impoverished future. We are now building a health care system for the poor, the jobless, the uneducated, the huddled masses, rising from within.<br />
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It would have been much easier to reform health care in America if we had the patience to wait a couple more decades until 80% of our children end up living in poverty, but in its infinite wisdom, our progressive government has decided that it is better to be prepared for this inevitable future of ours, and the sooner the better. Unfortunately, the remnants of what was once America the beautiful, are having a hard time understanding the dire need to reform health care for a posterity that looks eerily like Charlie & The Chocolate Factory. Fortunately though, we do live in the disinformation age, hence reeducating the public to see the preemptive benefits of the new ways, is just a matter of devising a solid marketing campaign.<br />
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Less is More</h3>
Simplicity, as any marketer can tell you, is the key to effectively inducing mass acceptance of new ideas.  Less is more. In this case less verbiage is more effective, but we don’t really need to get into subtleties. Plain less is just more of whatever you want more of. Let your imagination complete the message. Less is more, and less is always more, and more is actually less, and why would you settle for less, when you should rightfully have more by having less. Is there anyone out there that doesn’t know for sure by now that in health care less is more? Less superfluous tests, less useless screenings, less harmful drugs, less dangerous treatments, and all the misfortunes resulting from more of the same, in article after article, book after book, interview after interview, spread far and wide, less is more.<br />
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Note how everything is prepended with an onerous adjective to soften the ground and minimize resistance to the idea that less is not just more, but less is good. The next step is to point to research showing that more bad things are bad for you, and then extrapolate to stating that more of everything is bad for you, while all the time using undesirable adjectives before every noun. Less paternalistic doctors, less irresponsible ER visits, less murderous hospital stays, less confusing choices, less is always more. Always, because poor people need to internalize and accept that less is all they can ever hope for, and less is better than nothing at all. <br />
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Too Many Choices</h3>
Having no choices at all is usually associated with totalitarian regimes, but even in a free country beggars cannot expect to be choosers, or as insurance executives tell us, we are more "sensitive" to prices than we are to choices when we shop for health insurance. It seems we relish the idea of having less choices (less is more, remember?). Therefore, we have narrow networks, which are being rebranded to high-performing networks as we speak, to improve moral. The talking points say that narrow networks are cheaper because in return for lots of customers, doctors and hospitals, hungry for more patients, are giving the insurer greater discounts. So let’s see: it would be cheaper to only have NYU Langone and maybe Sloan-Kettering and their doctors in your narrow network, than having dozens more area hospitals and thousands of other doctors, right? Well, not quite, because poor people do better with surroundings more concordant with their station in life and we should be more thoughtful in the choices we make for them.<br />
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We are very fortunate to already have a health care program designed from the ground up for the poor, so there is no need to start from scratch. As millions and millions of American Homo sapiens are descending from trees and gaining health insurance for the first time in their life, two distinct choices are emerging from innovative public/private partnerships. Those who have reached stable poverty are rewarded with free access to tailored networks custom built for their needs, and those who are still struggling to get there, are gradually eased into similar networks, while all obstacles to achieving perfect poverty are slowly removed from their wallets. The hope is that all our citizens will one day benefit from Medicaid, at which point we can truly begin to <a href="http://www.medpagetoday.com/PublicHealthPolicy/Medicaid/46293?trw=yes&hr=kmd" target="_blank">mold our nation for the future</a>.<br />
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Who’s Your Daddy?</h3>
Poor people all over the world are acutely aware of being powerless to change their circumstances. Previously free and proud Americans are not likely to march willingly into the confines of poverty, unless of course, we can convince them that health care for the poor is actually an exercise in empowerment for the people. That’s a tall order for the best marketers, but we are executing on it flawlessly and brilliantly, because we had the wisdom to learn from past mistakes. Back in the nineties, America and its doctors rebelled against the yoke of managed care, and the HMOs pretty much failed. Today, we start fresh by breaking the unholy alliance between patients and their doctors, instead of expecting this to be an outcome of reform.<br />
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First we tell people that doctors are bossing them around too much, and that they keep secret documents about their patients. Empowered patients have a right to not let doctors advise them, and to see those classified files where all sorts of horrible things are written about each patient. Then to support our case, we establish through well researched anecdotal innuendos that doctors are greedy, incompetent, careless, and cannot be trusted. Next we make fun of people who “like” their doctors and want to “keep” them (like pets or old tee shirts), and we make sure that having the same doctor for lengthy periods of time is impossible going forward. Finally, we establish the insurer or the government to be your lord and protector in the perilous journey through the doctor infested waters of a “fragmented” health system. So let’s try that again, and this time we want the right answer: who’s your daddy now?<br />
<h3 style="text-align: left;">
The New Normal</h3>
The transition from being a free and wealthy nation to being just another medium size impoverished country, studded with magnificent sultans, may trigger a bit of anxiety, some anger and certainly lots of sadness in America. It is also well documented that mental disease is rampant among the poor, so we need to prepare. The old premise of an individual right to pursue happiness is now being upgraded to a personal responsibility to be happy. Screening for depression is becoming mandatory for all adults and children over thirteen years of age, and depression is assessed based on answers to nine questions, sometimes over the phone. Back in 2005, <a href="http://www.ncbi.nlm.nih.gov/pubmed/15939837" target="_blank">studies</a> estimated that almost half of Americans experience some sort of mental disorder during their lifetime. With the recent expansion to the definition of mental disorders, it is clear that by now the vast majority of Americans are pathologically disturbed. <br />
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But then again, if we are all hopelessly sad, overly angry and addicted to caffeine and such, aren’t we the ones that are “normal”? And perhaps the minority living in gated communities, unaffected by the looming better tomorrow, should be labeled with some sort of new disorder. We’ll leave that to the DSM VI (<a href="http://www.cnn.com/2014/02/05/us/texas-affluenza-teen/" target="_blank">and the courts</a>), and for an immediate solution to the poverty induced new normal, I would like to suggest a little innovation derived from dental medicine. Instead of wasting time and money on <a href="http://www.annfammed.org/content/12/2/183.2" target="_blank">integrating behavioral health into routine primary care</a>, why don’t we just cut through the chase and throw some Lexapro into the water supply? The new abnormal minority is not very likely to drink from a faucet anyway, so they should be safe.<br />
<h2 style="text-align: left;">
High Tech</h2>
Our success at keeping everybody informed, empowered and controlled, hinges on getting high on technology. This was the one missing piece in past attempts to create proper value chains, and just plain chains, for our citizens. Now that we succeeded in gluing most humans to a miniature computer permanently connected to our grid (sticking with calling it a phone was a brilliant marketing achievement), the rest is history in the making. If health care were a product, we could ship its manufacturing to where we ship all manufacturing, and make enough plastic versions of the original to satisfy our poor. But health care is a service, and here is where high tech comes to the rescue. By making enough hardware and enough software, and by strategically repositioning venues, you can productize services into manufactured goods. That’s how we replaced mom’s laborious cooking with packaged foods, for most poor people. And that’s how we will replace health care with health maintenance for the same. It will take time, thoughtful planning, lots of innovation and a carefully cultivated disdain for human life, but I have no doubt that our leaders will guide us safely to the bottom.</div>

There are over 16,000,000 American children (21.8%) who live in official poverty and double that number who are just poor. This is not ...

If You Want to Win, You May Have to Fight

10:20 PM Meme Art Studio 0 Comment

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<i>“Victorious warriors win first and then go to war, while defeated warriors go to war first and then seek to win.”</i> –Sun Tzu<br />
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According to the National Committee for Quality Assurance (NCQA), there are around <a href="http://recognition.ncqa.org/" target="_blank">33,000</a> Patient Centered Medical Home (<a href="http://www.ncqa.org/Programs/Recognition/PatientCenteredMedicalHomePCMH.aspx" target="_blank">PCMH</a>) recognized entities to date, <a href="http://www.ncqa.org/HomePage.aspx" target="_blank">5,560</a> of which are practices. Subtracting this and noting that many recognized entities are Nurse Practitioners (NPs), we can safely estimate that approximately 10% of the 209,000 practicing primary care doctors in the U.S. are working in a recognized PCMH. There are other accreditation bodies, but NCQA is by far the largest and best known, so the numbers above should be pretty indicative, give or take a few percentage points. My estimate is that another 80% or so of primary care physicians practice in unrecognized medical homes. Yes, 80%. Although it is difficult to get exact numbers, perusing the NCQA lists of PCMH shows that a large number of recognized medical homes belong to health systems, academic centers and community health centers.<br />
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According to the Office of the National Coordinator for Health Information Technology (ONC), <a href="http://www.healthit.gov/providers-professionals/healthcare-providers-and-health-information-technology-infographic" target="_blank">72%</a> of office-based physicians were using some sort of EHR in 2012, and 66% either demonstrated or are planning to demonstrate Meaningful Use. As with medical home recognition, EHR ownership is also skewed in favor of larger practices, with solo docs in particular, lagging significantly behind. <br />
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And then there is the <a href="http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/PQRS/" target="_blank">Physician Quality Reporting System</a> (PQRS), with or without Maintenance of Certification (MoC), and the legacy <a href="http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/index.html?redirect=/erxincentive" target="_blank">electronic prescribing</a> initiative, and the upcoming <a href="http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html" target="_blank">Value Based Modifier</a>, all from Medicare. Private payers, and sometimes States, have their own slightly different pay for performance (P4P) programs. And all these programs are layered on top of a thick and knotty web of rules and regulations, specifying medical necessity, need for prior authorizations, medications formularies, the amount of text and the terminology needed to justify payments, and everything comes in as many flavors as there are health insurance plans. <br />
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Health systems and large medical groups have dedicated departments and staff to oversee and take advantage of all these programs, better known as quality initiatives, and that’s why they need to collect additional <a href="http://www.publicintegrity.org/2012/12/20/11978/hospital-facility-fees-boosting-medical-bills-and-not-just-hospital-care" target="_blank">facility fees</a> (and, according to the American Hospitals Association, also because of the <i>“threat of terrorist attacks, recent mass shootings, the aftermath of Hurricane Katrina and the devastating tornados</i><i> over the past year”</i>). Small practices, on the other hand, have nothing but angst. The vast majority is resentfully struggling to keep the balls in the air in haphazard ways guaranteed to eventually fail, and a small (but growing) minority is  taking their toys and going home to practice cash-and-carry medicine. But here and there, you find the anomalous independent practice that is thriving; still chock full of resentment, but with a smile, because when you outsmart your opponent, it’s satisfying to acknowledge that this was (is) a powerful (dangerous) opponent indeed. So what’s the secret sauce? And is it scalable to all other soon to disappear independent physicians?<br />
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Let's begin with the medical home because some solutions are embedded in its concept, and because the brand new NCQA Patient Centered Specialty Practice (<a href="http://www.ncqa.org/Programs/Recognition/PatientCenteredSpecialtyPracticeRecognition.aspx" target="_blank">PCSP</a>) recognition extends the same model to physicians who are not practicing primary care. First let’s assume that you chose to be a doctor so you can take care of patients, and this is still what you would prefer to be doing, but an extensive and growing bureaucracy along with shrinking payments, is preventing you from providing the care you believe you should be providing to your patients. If your aspirations are different, or if you are one of the few physicians who made the switch to cash pay, what follows will be of no use to you.  <br />
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For illustration purposes, let’s look at a solo practice, because whatever works for a solo practice, can be easily extrapolated to a larger group (but not vice versa). The <a href="http://www.acponline.org/pressroom/pcmh.htm" target="_blank">first</a> and most fundamental tenet of the medical home model is the personal physician, i.e. a person with an MD or DO, who is supposed to create a continuous relationship with an individual patient. It is worth noting that primary care practices led by non-physicians are by definition not Patient Centered Medical Homes, regardless of the <a href="http://www.nejm.org/doi/full/10.1056/NEJMsa1212938#t=article" target="_blank">current push</a> to the contrary. Unfortunately, NCQA is deferring to State laws, and will recognize medical homes without a physician and/or medical homes where a non-physician is substituted for some patients, but NCQA does not dictate that non-physicians should provide primary care. So basically, it’s up to you to implement this any way you see fit. You are not required to hire non-physicians or delegate patient care to other people. PCMH merely asks that you build a long term personal relationship with your patients.<br />
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If that’s the case then how about team care, huddles and that sort of thing? To answer this question, I would suggest a small exercise. <b>Exercise #1:</b> read the PCMH standards and substitute the word “staff” everywhere you see “team”. Does it read better now? Replacing the term “staff” with the term “team” is a semantic innovation that is sweeping every business everywhere. It is not limited to health care and it should not elicit visions of an egalitarian system where nobody is in charge. In case you are not aware, every business executive that used to have staff and staff meetings, now has a team and team meetings. Same people, same reporting hierarchy, with added feel good validation for employees, usually in lieu of promotions and salary raises. If this rationalization is sufficient to deter the knee-jerk reaction to the PCMH language for a few minutes, let’s look at the measures associated with this PCMH concept. <br />
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In some cases when you try to address a behavioral or chronic problem for a patient, the first step is to have the patient keep a log of their current activities and gain awareness of what may need modification in order to effect beneficial change. Let’s try that. <b>Exercise #2: </b> for a couple of days, keep a piece of paper in your pocket, and note all your activities as you go through your workday, then sit down and mark the ones that have nothing to do with actual patient care, and of those, mark the ones that have nothing to do with your medical education. Now ask yourself why you are doing these things instead of having your staff deal with them. Be honest. Is it that you don’t trust your staff to do things right? Is it that it takes less time to just do it, instead of having to explain everything every single time? Is it that everybody seems already too busy? Or maybe it’s just because this is how it always was?<br />
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Now let’s try something a bit harder. <b>Exercise #3:</b>  on that piece of paper you are carrying around, note your activities when the patient is in the room, in other words, analyze your patient care. Write down how much time you spent looking for information in the chart, how many times you had to step out to give some orders or request things from staff, how much time you spent talking about administrative things, or things that don’t require medical training, and how much time you spent collecting and cataloging standard information that has very little to do with the problem at hand (yes, I know, your EMR sucks; write it down). To be clear, this is not intended to shorten the time you listen to the patient or constrict the conversation in any way. This exercise is aimed at identifying tasks and activities that could be done by staff, preferably in advance of your visit with the patient, precisely so it can free a few more precious seconds for the two of you. I don’t need to tell you that seconds add up to minutes and minutes add up to hours and hours add up to missed opportunities. And yes, it is a sorry state of affairs when we must devolve to counting seconds.<br />
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The last exercise in our series will help you identify another very common problem. <b>Exercise #4:</b>  go to a couple social media sites where patients rate doctors (Yelp is a good one) and browse through the various comments. This is not to encourage you to submit to patient reviews, but to illuminate a very common problem in the form of a great doctor, but rude, unhelpful and impatient staff. You may be the greatest and most compassionate physician out there, and your patients will appreciate that and stick with you no matter what, but are you OK with staff that either does not know how, or does not care enough to treat your patients well?<br />
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After completing these four exercises, go back and read the “care team” measures in the NCQA standards (remember to substitute “staff” for “team”). Do you see anything that may be helpful with whatever problems you managed to identify through our little experiments? We’ll look at some possible answers in the next post. And by the way, if you are still questioning the necessity of doing anything other than keeping your nose to the grind and going faster and faster every passing day, you should note that once again medicine is changing. It changed before and it will most likely change again, and those who happen to practice the art, science and business of medicine during times of great change, are rarely pleased with the upheaval. Some will be decimated in the process and others will survive and thrive. Which one would you rather be?</div>

finances financial If You Want to Win, You May Have to Fight

“Victorious warriors win first and then go to war, while defeated warriors go to war first and then seek to win.” –Sun Tzu According t...

1:19 AM Meme Art Studio 0 Comment

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<b><span style="font-family: "arial" , "helvetica" , sans-serif;">Don’t Over-Tax Yourself Over Tax Season!<o:p></o:p></span></b></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">With the April 15 tax deadline looming, it’s an anxious time<br />for many people. Try these tips to keep your financial stress under<br />control at tax time — and all year round.<o:p></o:p></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgl2jxsL-zj_8sVsrKyCpwCzTFjduCbR_npOlEG-38x7JsGCk634RdvZUOwjaOZpXtvkw0GMDOk62KLuoCPMMGqOwh00CLFNs1JmuZAbIwjJ-k0u-SXzvbQri7hOu49tF3nxnEokD7DvCgG/s1600/tax+couple.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="213" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgl2jxsL-zj_8sVsrKyCpwCzTFjduCbR_npOlEG-38x7JsGCk634RdvZUOwjaOZpXtvkw0GMDOk62KLuoCPMMGqOwh00CLFNs1JmuZAbIwjJ-k0u-SXzvbQri7hOu49tF3nxnEokD7DvCgG/s1600/tax+couple.jpg" width="320" /></a><span style="font-family: "arial" , "helvetica" , sans-serif;"><b>Break It Up. </b>A mountain of paperwork for your tax<br />return or for any other financial responsibility, like applying for a college<br />loan or mortgage, can seem overwhelming. Break up the process into smaller<br />chunks, such as gathering pay stubs, finding your home mortgage interest<br />statements, or organizing your receipts. Then tackle each task one by one. But<br />before you do so…<o:p></o:p></span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><b>Make a Plan. </b>This is even more important when you’re<br />on a tight deadline (like being just a few days away from April 15). Once<br />you’ve broken down what you need to accomplish into pieces, put those steps in<br />order and write down how and when you’re going to make each one happen. This<br />will help you feel like you have control over the process. Being out of control<br />is very stressful!<o:p></o:p></span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><b>Keep Mentally Fit. </b>Eat well, get a full night’s<br />sleep, find a way to exercise every day, and connect with friends and loved<br />ones. Financial deadlines may have you feeling like you need to lock yourself<br />away and pull an all-nighter with a bag of potato chips and your 1040, but<br />you’ll just raise your stress level, and you probably won’t accomplish your<br />goal anyway. <o:p></o:p></span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><b>Resist Unhealthy Temptations. </b>When stress arises,<br />it’s tempting to cope in unhealthy ways such as binge eating, smoking, or drinking<br />alcohol. Avoid these negative coping strategies. Instead of a cigarette or a<br />glass of wine, take a walk or call a friend to vent. <o:p></o:p></span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><b>Don’t Go It Alone. </b>It’s not too late to get help. Ask<br />for help from a spouse, a trusted friend, or ideally, a financial professional<br />like a certified public accountant. Some tax professionals will even save you<br />the step of visiting their office and will review your documents and<br />calculations online. Having too much on your shoulders and no help is a recipe<br />for anxiety.<o:p></o:p></span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><b>Request an Extension. </b>If you’re utterly overwhelmed<br />and you feel like there’s no way you’ll have it all together by April 15, talk<br />to a tax professional about how to request an extension on filing. You’ll still<br />have to pay your estimated taxes on time (or pay interest), but you’ll have an<br />extra six months to get your paperwork in order. <o:p></o:p></span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><b>Plan Ahead for Next Year. </b>If you’ve procrastinated<br />about your taxes this year, use the stress you’re experiencing now as you try<br />to get everything together at the last minute for a good cause: Keeping you on<br />track to plan ahead for tax time 2016. Set a realistic budget and stick to it,<br />and keep track of your finances as you go along. Having a plan and living<br />within your means makes your life much less stressful.<o:p></o:p></span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">by <a href="http://nyulangone.org/doctors/1558358457/david-l-ginsberg">David Ginsberg,<br />M.D.,</a> clinical associate professor and vice chair for clinical affairs,<br />Department of Psychiatry, and chief of the Psychiatry Service, NYU Langone<br />Medical Center in New York City.<o:p></o:p></span></div>
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finances financial health mental health money stress wellness

Don’t Over-Tax Yourself Over Tax Season! With the April 15 tax deadline looming, it’s an anxious time for many people. Try these ...

What’s Up Doc? Medicare Carrots and Sticks

6:35 AM Meme Art Studio 0 Comment

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The Patient Protection and Affordable Care Act (PPACA) of 2010 mandates that certain administrative simplifications should be made to reduce overhead costs of health care. Since administrative complexity obeys the conservation laws of physics, for every bit of complexity that is removed, a new chunk of bureaucratic complexity must be added to the system. With that in mind, <a href="http://www.ama-assn.org/resources/doc/cqi/pcpi-032912-rapp.pdf" target="_blank">CMS has created</a> and is proposing to grow an array of <a href="https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads//EHRIncentivePayments-ICN903691.pdf" target="_blank">financial incentives</a> and penalties for health care providers. This collection of carrots and sticks is intended to be used as so many levers to control and fine tune the practice of medicine by encouraging adoption of health information technology, measuring processes and steering physicians to low cost treatment methods.<br />
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Since confusion is abundant, and confusion leads to anger, fear and sometimes outright panic, which in turn causes folks to dump perfectly good private practices on the first hospital that knocks on their door, I thought it would be beneficial to clarify a few things and look at the situation from an objective mathematical perspective. Below are concise descriptions of the current CMS incentives and penalties programs, and a dollar amount evaluation of their possible effect on your bottom line.<br />
<h4>
    Electronic Prescribing</h4>
A bit outdated in the EHR era, the <a href="http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/index.html?redirect=/ERXincentive" target="_blank">eRx incentive program</a> began in 2009 and is due to expire in its entirety by 2015, when no bonuses and no penalties will be assessed for this initiative.<br />
<b>The Rules:</b> Currently, 10 electronic prescriptions in the first half of the year will ward off the penalties for next year, and 25 electronic prescriptions during the entire year will get you the incentive next year. The prescriptions must be written for Medicare patients’ unique visits with associated E&M codes and a “qualified” electronic prescribing system must be used. Any eRx module in a certified Complete EHR will do and if you use a standalone system, make sure it states that it is “qualified” for CMS incentives.<br />
<b>The Numbers: </b>The incentives are 1% this year and 0.5% in 2013. There are no incentives available after that. Incentives are calculated as a percentage of the total Medicare Physician Fee Schedule (MPFS) allowable charges for the calendar year. The penalties are -1%, -1.5%, -2% in 2012, 2013 and 2014 respectively. There are no penalties after 2014. Penalties are applied as an adjustment to ongoing MPFS payments during the penalty year. Note that you cannot receive eRx and Meaningful Use Medicare incentives in the same year. You can do so for Medicaid EHR incentives.<br />
<h4>
    Physician Quality Reporting System (PQRS)</h4>
This is <a href="http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html" target="_blank">the successor</a> of PQRI (the “I” was for initiative) and it started in 2010 in its current format with no proposed expiration date. It is important to keep in mind that the contents of your PQRS reports will be made public on the Physician Compare website maintained by CMS.<br />
<b>The Rules:</b> You will have to report on at least three clinical quality measures, or one group of measure, for the reporting year. You may report your measures via claims, registries, EHR or a special group reporting tool. The reporting is limited to Medicare patients and although the registry option offers a 6 months reporting period, most other methods require that you report on 30% to 80% of pertinent patients for the whole year. If you choose claim reporting, make sure you don’t let charges entered close to year-end linger around, because CMS may not get them in time to calculate your incentive. Both Incentives and penalties are calculated and applied as they are for the eRx program.<br />
<b>The Numbers:</b> You could have gotten a 1% incentive in 2011, but starting in 2012 and through 2014, the incentive is a constant 0.5%. There are no incentives authorized after 2014. Penalties begin in 2015 with -1.5% and continue to -2% from 2016 and beyond. There is no end date for the penalties. PQRS incentives are independent of eRx and Meaningful Use and may be combined with either one.<br />
<h4>
    Maintenance of Certification (MOC)</h4>
The <a href="https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Maintenance_of_Certification_Program_Incentive.html" target="_blank">MOC program</a> is only available for those who successfully report PQRS measures and is available only through the incentives phase of PQRS.<br />
<b>The Rules:</b> You need to participate in a Maintenance of Certification program and complete a practice assessment more frequently than is required to qualify for or maintain board certification. Make sure that your board is indeed qualified by CMS for this program, since not all are. <br />
<b>The Numbers:</b> This is a very simple program that will pay an additional 0.5% of MPFS to what you already receive for PQRS reporting. The program expires after 2014 and there are no penalties associated with it.<br />
<h4>
    The EHR Incentives Program (Meaningful Use)</h4>
Saving the best for last, this is the big one and most advertised one. The <a href="https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html" target="_blank">Meaningful Use program</a> started in 2011 and is projected to continue indefinitely. It has been likened to an escalator, where the requirements become more comprehensive and more complex every two or three years. <br />
<b>The Rules:</b> You must buy an ONC Certified Complete EHR (or a collection of certified modules) and meet a set of required measures every calendar year. The measures are adjusted every two (or three) years, from the current Stage 1 to future Stages 2, 3 and presumably others. There are two tracks for this program, one for Medicare and one for Medicaid participants. Meaningful Use is a very comprehensive set of measures reaching into every aspect of medical practice and is inclusive of both electronic prescribing and the reporting of clinical quality measures. The EHR incentives program and the electronic prescribing program are mutually exclusive under Medicare incentives.<br />
<b>The Numbers:</b> The program offers 5 years of decreasing incentives followed by incrementally increasing penalties for non-participation. The maximum incentives under the Medicare track is $44,000, plus 10% of that if you practice in a designated health professional shortage area, and $63,750 for the Medicaid track. You can join the Medicare track as late as 2014 (you will lose about half the incentive) and the Medicaid track can be started as late as 2016 with no loss of incentives. However, in 2015 penalties, in the form of adjustment to your Medicare allowed charges, will begin to apply for those not participating in either track. CMS is proposing to backdate the penalties, so they apply in 2015 to those who have not become Meaningful Users by October 1st of 2014, effectively moving up the compliance date mandated by legislation. The penalties start at -1% of MPFS in 2014 and increase by 1% every year until they reach -5% in 2019 and continue at the -5% level indefinitely.<br />
<h4>
    Bottom Line</h4>
For illustration purposes, let’s say you see 10 Medicare patients every day, you work 5 days every week and 50 weeks every year in a health professional shortage area. Accounting for different E&M charges, you are looking at approximately $200,000 per year paid to you by Medicare, and clearly this is a best case scenario. Let’s further assume that the proposed reimbursement cuts and the proposed increases to primary care reimbursement balance each other out and your Medicare revenue stays flat in today’s dollars. How will the carrots and sticks affect your income?<br />
<b>Scenario 1:</b> You do all that is required and are rewarded with nothing but carrots between 2011 and 2020. In addition to your claims reimbursement, you will receive from CMS $57,400 over the current decade, which is $5,740 per year or $478 per month, totaling less than 3% increase in your average Medicare reimbursement. <br />
<b>Scenario 2: </b>You ignore all CMS programs and do your own thing, and stick with your decision through 2020. You will of course not get any incentives and you will lose a total of $72,000 over this decade, or an average of $7,200 per year, which is $600 per month, or the equivalent of 3.6% of your Medicare revenue over 10 years. <br />
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It is important to note that, while the incentives are temporary, the penalties are applied indefinitely, converging to 7% MPFS, or $14,000 per year in our imaginary scenario. The sticks are larger than the carrots. These numbers do not bring into account costs of opportunities lost, such as performance bonuses and additional payments per-member-per-month that are becoming available from private and public payers for special endeavors such as medical homes and other quality improvements, and require the same infrastructure be exercised in the same fashion as the Medicare incentives programs described above.<br />
<h4>
    But wait, there is more: The Value Based Payment Modifier (VBPM)</h4>
If you are fortunate enough to practice in Iowa, Kansas, Missouri, or Nebraska, you are part of a preamble to <a href="https://www.cms.gov/PhysicianFeedbackProgram/" target="_blank">a new Medicare program</a> which proposes to add a modifier to your charges based on the ratio of cost to quality for services rendered to Medicare members. So far physicians of all specialties in the selected pilot States have received Quality and Resource Use Reports (QRURs) outlining their performance and costs based on 2010 claim submissions. The program is in its definition stage and there are no clear numbers associated with the proposed modifier, and no explanation on how such modifier would be calculated, but it seems that by far, this is going to be a much more significant stick or carrot than anything outlined above. The legislation mandates that this program goes into effect in 2015 and by 2017, most physicians paid under the MPFS will see the VBPM applied to claims they submit to Medicare. [More on the VBPM in a future post…]<br />
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<tr><td class="tr-caption" style="text-align: center;"><b><span style="font-family: "calibri" , "sans-serif"; font-size: 11.0pt; line-height: 115%;">CMS incentives and penalties proposed programs 2011-2020 (click to enlarge)</span></b></td></tr>
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 These are the visible carrots and sticks. Now it’s your turn to do the math and make your decision. Note that Scenarios 1 and 2 above are the extremes. You can always jump on the wagon at a later point, with less incentive and/or less penalties. The wagon, though, is accelerating pretty quickly.</div>