Physician Recruiter Blog: September 2007

Wednesday, September 26, 2007

Excellent Career Tips for Physicians

Tuesday, September 25, 2007

On Call 24/7& 365 and Handling common problems within a private practice

Being Available to Patients 24/7 Can Be Stressful but Gratifying -From the NY Times
On call 24/7… Another story of physicians offering services that many don’t. What the article doesn’t tell us is how these after hours calls are billed. I assume they are billing premium rates for these calls, which would make sense. Like I said in my last post, Americans pay for convenience….

- WJ

Toughest practice problems SOLVED
Our roundtable experts have the cure for what ails you, whether it's declining reimbursements, billing bottlenecks, long hours, or unhappy patients. –From Medical Economics
This is a very interesting discussion of four common “problems” physicians in private practice face. I’m a big fan of Medical Economics and this is another well done article and a great read. Just as a tease, here are the summaries each of the experts gave for conquering the “problem” each was assigned to discuss.

Quote:

ZETTER'S SUMMARY: To boost revenue, add an ancillary service
Calculate whether the ancillary service will pay for itself.
Speak with a healthcare attorney about compliance with federal self-referral regulations.
Consider ancillary services that self-referral regulations don't cover.
Address practice management problems before adding a new service.

BORGLUM'S SUMMARY: To meet patient demand
Hire one or more midlevel providers.
Extend your office hours to cover early morning, early evening, or both.
Drop health plans that pay poorly, one at a time.

COHEN'S SUMMARY: To reduce in-office waiting time
Time each stage of a visit to pinpoint logjams.
Mail new patients registration packets, with return envelopes.
Offer online registration for the Internet-savvy.
Streamline registration forms for ease of use.

BRADY'S SUMMARY: For adding a physician
Assess the existing space and its uses.
Make room for additional staff or providers by moving paper versions of computerized records off-site.
Ensure that each doctor has an adequate number of exam rooms.
Extend office hours and stagger physician schedules.

Enjoy!

- WJ

Monday, September 24, 2007

Sneak peek @ 2007-08 TheRecruiter.com Salary Report

Here's an early at our Physician/Surgery data for our Salary Report. Check TheRecruiter.com in coming weeks for the formal report.

Specialty
Low Range
Average
High Range

Allergy/ Immunology
$168,945
$225,693
$374,872
Ambulatory
$92,549
$121,412
$168,219
Anesthesiology
$243,157
$314,218
$460,437
Anesthesiology - Pain Management
$286,086
$362,290
$551,071
Anesthesiology - Pediatrics
$264,923
$317,431
$424,761
Cardiology - Invasive
$258,210
$365,360
$542,295
Cardiology - Noninvasive
$261,543
$368,027
$526,295
Cardiology - Pediatrics
$192,654
$283,823
$468,025
Cardiology -Interventional
$268,877
$389,694
$596,962
Cardiovascular Surgery
$329,342
$466,667
$682,578
Child and Adolescent Psychiatry
$158,821
$202,524
$283,356
Critical Care
$190,601
$229,167
$326,862
Critical Care - Pediactrics
$162,823
$214,329
$311,545
Dermatology
$217,515
$304,312
$432,540
Emergency Medicine
$188,274
$227,240
$315,264
Endocrinology
$155,328
$188,338
$262,792
Family Practice - Sports Medicine
$152,379
$215,787
$325,588
Family Practice w/ OB)
$152,491
$187,180
$246,901
Family Practice w/o OB
$141,842
$159,122
$239,166
Gastroenterology
$265,695
$343,834
$514,693
General Surgery
$225,247
$295,086
$450,179
Gynecology
$167,780
$220,711
$328,632
Hematology/Oncology
$207,297
$271,625
$494,021
Hematology/Oncology- Pediactrics
$190,906
$241,219
$320,085
Hospitalist
$149,524
$176,919
$248,786
Infectious Disease
$151,508
$187,404
$269,364
Internal Medicine
$143,432
$177,085
$244,848
Maternal/Fetal Medicine
$260,700
$328,785
$512,939
Medical Oncology
$188,181
$258,804
$393,678
Neonatal Medicine
$256,789
$302,886
$405,948
Nephrology
$196,619
$277,782
$411,961
Neurological Surgery
$341,831
$480,119
$730,940
Neurology
$168,021
$215,109
$309,459
Neurology - Pediactris
$164,164
$193,621
$303,263
Obstetrics/Gynecology
$197,097
$254,119
$372,629
Occupational Medicine
$133,527
$184,878
$268,893
Ophthalmology
$189,830
$294,333
$435,501
Ophthalmology Retina
$285,227
$416,219
$601,916
Orthopedic Surgery
$291,654
$380,861
$596,350
Orthopedic Surgery - Foot & Ankle
$273,883
$385,621
$620,060
Orthopedic Surgery - Hand & Upper Extremities
$295,108
$409,621
$615,405
Orthopedic Surgery - Hip & Joint Replacement
$357,426
$474,130
$672,297
Orthopedic Surgery - Spine Surgery
$401,473
$594,544
$969,632
Orthopedic Surgery - Sports Medicine
$287,330
$451,544
$661,824
Pathology
$193,640
$289,177
$458,009
Pediatrics
$138,546
$175,265
$257,043
Pediatrics
$131,748
$174,119
$252,149
Physiatry
$162,835
$237,096
$322,079
Plastic Surgery
$257,986
$381,660
$614,846
Podiatry
$134,197
$177,405
$267,051
Psychiatry
$143,381
$177,008
$247,988
Pulmonary - Critical Care
$178,661
$232,920
$330,213
Radiation Oncology
$259,566
$366,440
$595,212
Radiology
$208,069
$345,471
$621,484
Radiology - Diagnostic
$354,450
$418,997
$588,395
Rheumatology
$170,843
$231,166
$342,437
Urgent Care
$139,184
$191,562
$275,165
Urology
$254,580
$342,604
$518,376
Vascular Surgery
$270,175
$344,873
$503,807

New Times, Old Methods

Retro Medicine: Doctors Making House Calls (for a Price) and Location, Location, Location: A Key to Good Health, Too – both from NY Times

Americans will pay for convenience and house calls are certainly that. As a non-medical professional who works around the medical world, I’ve always marveled and shaken my head a bit at the “behind-the-timesness” of the business of practicing medicine. Niche practices like house calls and retail clinics are the sort of value added service angles that non-medical businesses have been cycling through for years -- it’s interesting to see this sort of paradigm shift (or attempt by some to make one). Of course house calls are an old thing , really, in medical practice, but the commonality of the practice was lost in another paradigm shift long ago. I will be watching to see what the insurance companies do about these things. I also wonder what sort of impact these sorts of market changes will have on physicians. What will happen with compensation, hours, malpractice, available jobs, etc??

- WJ

Wednesday, September 19, 2007

A Few Good Reads for a Wednesday

States Differ Widely in Spending on Health Care, Study Finds – NY Times

Why Clinton Embraced Employer-Based Insurance – Wall Street Journal

Gone But Not Forgotten: Medicare Cuts, Money for Docs – WSJ Health Blog

Americans Want Leaders to AddressCoverage for Uninsured, Poll Shows – Wall Street Jourtnal

A lesson outside the office – LA Times

Friday, September 14, 2007

An open letter to A Physician On...

Matthias Muenzer of A Physician on Job Search and Practice welcomed the PR Blog in a post on Sept 4. A few days later, Matthias posted a fairly scathing response to my posting on MPC and the Doctor Job – but that post has now apparently been removed from A Physician On… One assumption that has been made by Matthias is that I am a physician recruiter. I tried to respond to his original “welcome” post, but my response comment has not shown up on his blog. For anyone who is a reader of either blog and might be similarly confused about what TheRecruiter.com and Physician Recruiter publication are all about, here is what I attempted to post on A Physician On…

Matthias,

I have been on vacation and came by to read your blog last night and read both this entry and the one which you've apparently deleted about my blog. Perhaps, I shouldn't have waited to respond to the other blog....

I'd like to clarify one erroneous assumption you're making about the Physician Recruiter blog as an entity and me as the main author: I am NOT a recruiter. I am a publisher, and Physician Recruiter is a 20 year old newspaper specializing in publishing practice opportunities and career management news with a circulation of over 200,000 physicians nationwide. TheRecruiter.com is the related website. Our aim is to provide a vehicle for physicians to find opportunities and hospitals, private practices and recruiters to source candidates, as well as to provide interesting and valuable career management information for physicians.

We realize that there are many different ways for physicians to go about finding their next opportunities and many different ways for hiring authorities to find their next hire. We make hundreds of outgoing calls to hiring authorities at hospitals, clinics and small practices as well as 3rd party recruiters everyday. We also have contact with many physicians and medical professionals. We hear their stories and strategies regarding recruiting and job search and different people have different feelings and experiences with all different methods. Some hiring authorities and physicians have great success using 3rd party recruiters, some, like yourself, have had poor experiences. Some swear by this or that print publication, while other take a web only approach. Some love direct mail, others feel it’s too expensive. Some like retained search recruiters because their jobs are guaranteed to receive attention, while others prefer contingency based recruiters because they don’t limit a hiring authorities options and there is no cost unless a placement is made.

Our position on all of this: be you a hiring authority or a physician seeking a new opportunity, do what it takes to meet your objective. If this or that method isn’t working or makes you uncomfortable, then try something else. There is no single right answer.

While I can understand and respect your point of view regarding recruiters, in particular, it is evident to me that you point of view is a skewed one. While there are recruiters who provide the sort of negative experiences that fuel your vitriol, there are some terrific recruiters out there who do a great job and have very loyal customers.

On the first hand, I spoke with a recruiter the other day who is currently “working” more than 120 jobs. I asked this person how they could possibly work that many positions and the answer was (paraphrasing) “Well, I give most of my attention to the handful of positions that are fill-able”. In other words, only 5-10% of those jobs are getting any attention. In my opinion, this is a huge negative to both the hiring authorities as well as the candidates that this recruiter is “representing”. On the other hand, we recently spoke with a large hospital that is perpetually recruiting. This hospital was a client of Physician Recruiter for years and years, spending tens of thousands of dollars on advertising, but close to 2 years ago they stopped advertising with us. They didn’t stop because they weren’t getting results with us and wanted to advertise in Brand X journal or on ABC.Com Job board, they stopped advertising with us because a contingency recruiting firm was doing a great job for them, taking work load off their shoulders and finding great candidates. While they are spending exponentially more money paying fees than they were advertising with us, this hospital is happy because it’s working and they see it as a value. While not a success story for my own business, I have to give the recruiters a lot of credit in this case.

The bottom line is this. Whether hiring or on a job hunt, keep an open mind. Some things work for some people some of the time, others don’t. Find what works for you, but be prepared and open for change if you need to make one, because no method is going to work all the time.

--Will Johnson

Wednesday, September 12, 2007

Computers in the examining room....

My primary care doc started using computerized medical charts in the examining room within the last couple of years. I have noticed that the my doc (and his NPs, whom I sometimes see) do spend a fairly significant amount of time in front of the computer during a visit. That said, I do not feel that their level of attention toward me has diminished at all or that the level of care I receive has been affected. In fact, I have found that when I do have questions, the computers have allowed my physician to quickly located and print out information, or just discuss it with me right there in the room instead of waiting for the nurse to retrieve pamphlets or photocopies that may or may not be in stock. To me this is a good thing.

Besides, we give our scientists and business professionals computers because automation is extremely helpful in collecting and storing data. Hard science and business would not be as advanced as they are today without these tools, so why would anybody want to tie a physicians hands by not allowing them to take advantage of such a tool. Does the exam room look different? Yes. Is there a change in interaction between physician and patient because of the presence of the computer? Some. Does this technology allow doctors more access to information more quickly and help in storing and disseminating medical data? Yes. Is the change worth it? Yes.

From the Boston Globe….

Eyes shift from patient to keyboard
By Dr. Michael Hochman September 10, 2007

When I began my residency last year at the Cambridge Health Alliance, I was thrilled to discover that I would be using a computerized medical record system. Computerized medical records - which are now used by about half of Massachusetts physicians and a growing number of doctors nationwide - are truly revolutionizing medicine, allowing doctors to chart patient information more safely, effectively, and legibly than ever.

Although the computerized system has proven to be a huge help, I have confronted an unexpected challenge: Despite repositioning the computer in every imaginable way, I often find myself making more eye contact with the screen than I do with my patients. It is simply more difficult to face a patient while typing than while writing.

When I ask my patients whether the presence of the computer bothers them, most are understanding (though one pugnacious older lady told me that my face looks better from the side anyway).

Still, a growing body of research is showing that computers affect the dynamics of the doctor-patient encounter. A study published earlier this year in the Journal of General Internal Medicine showed that about a quarter of patients felt as though computers reduced the amount of time their doctors spent talking with, looking at, and examining them. But just 8 percent felt that the computer actually interfered with the doctor-patient relationship. Interestingly, patients who saw resident physicians - doctors still in training - were more likely to express concerns, perhaps because experienced doctors are more likely to have well-established relationships with their patients.

In another study from 2006, doctors in Israel who had a computer in their office spent about a quarter of the visit looking at the computer screen (I probably spend at least this much time). The study also showed that the more time doctors spent typing, the less time they spent talking with their patients.

Computers also make the doctor-patient encounter a bit more routinized. In medical school when I used paper charts, I would collect information in a systematic but somewhat artful manner. For example, I would broach the subject of alcohol, tobacco, and drug use slightly differently with each patient. Now, my history taking has become more mechanical. I ask about alcohol, tobacco, and drug use by reading from a checklist of questions on the computer screen.
If used correctly, however, a computer can have positive effects on the doctor-patient relationship. In particular, the computer makes it easier and faster to read through the chart and find information about a patient such as his or her medication list, occupation, and the names and ages of any children. A 2005 study by researchers from Kaiser Permanente found that, after the introduction of a computer in the office, patients were more likely to feel that their doctors were familiar with their history.

Since computerized records are here to stay, the question is what can be done to ensure that computers will enhance - rather than interfere with - the doctor-patient relationship.
When I asked one of the more experienced doctors at my hospital how she deals with having a computer in the room, she said that she acknowledges the problem up front by apologizing to her patients for turning away from them. This helps her patients recognize that she is doing her best to communicate with them on a personal level even though she can't actually face them for large parts of the visit. She also makes sure to end all visits by turning away from the computer and toward her patient while going over everything that was discussed.

Additionally, patient visits may require more time when a computerized system is used - the opposite of recent trends. It is much more difficult to type while listening to a patient talk than it is to write. Also, because information is now more easily accessible, doctors may spend more time reviewing old notes. The upside of this, however, is that more can potentially be accomplished with each visit.

Finally, at a practical level, those sixth grade touch-typing skills are coming in more handy than ever. A few dexterously gifted colleagues of mine claim they can type their notes while maintaining eye contact with their patients. Perhaps remedial touch typing should be a requirement in medical school nowadays?

Like any new technology, computerized medical records affect patient care in both positive and negative ways. But overall, the balance is undeniably favorable.

Still, I can't help but feel as though my interaction with patients has become a bit less personal.

© Copyright 2007 Globe Newspaper Company

Convenience breeds competition and change.

From a business standpoint, retail medical offices have the potential to greatly change the landscape of private practice. Here is the point of view of one doc who's embracing the change and jumping on thr bandwagon.

From the Wall Street Journal.....

Retail Clinics Put Pressure on Doctors
September 11, 2007
By BENJAMIN BREWER, M.D

An uninsured patient came to my office recently after a weekend visit to the emergency room at the local hospital. He had gone to the ER complaining of dizziness, an earache and generally not feeling well.

The ER staff looked him over, cleared out his impacted earwax and referred him to a mental health clinic for depression. Afterward, the hospital presented him with a bill for $600.
An ER isn't the best place to get basic care. It's expensive for the patient and inefficient for the hospital. My new patient would have been better and more cheaply served with an office call or a visit to a retail clinic.

The possibility of a retail clinic in the town's only grocery store has the local docs fighting mad. Clinics in drug stores and other retail settings started out catering mostly to the uninsured. But 40% or more of the care given at the clinics these days is covered by insurance companies, a trade group for the clinics says.

The doctors who oppose retail clinics say they are cherry-picking the best business. Easy and profitable visits for sore throats and sinus infections break up an otherwise grueling day of time-consuming patients ill with diabetes, dementia and heart disease.

To fight the planned retail clinic, the local doctors have threatened to stop referring patients for surgery and specialized care to the big, multi-specialty group from out of town that's looking to open it. The business the group would lose by offending the local doctors could offset any gain from a retail clinic. So far no clinic has arrived.

Elsewhere in Illinois, and across the country, retail clinics are coming. Doctor groups aren't happy about them. The Illinois State Medical Society, for one, is pushing for such strict regulation of clinics that they'll be hard to set up or operate profitably.

I think that's a disservice to uninsured patients who can't easily access or afford health care. It also doesn't acknowledge patients' interest in quick, convenient care for uncomplicated conditions. My response to the outcry from my colleagues is: When all else fails, improve the product.

My traditional practice has always tried to be flexible in serving patients. My partner and I offer everything from obstetrics care to geriatric services. We carve out time or work through lunch to offer same-day appointments. Local HMO patients rated us above average in ease of getting an appointment and time spent with the doctor.

My home number is listed in the phone book, and I take calls after hours and on weekends for emergencies. We're adding another doctor to the practice this year so we can offer some evening hours and Saturdays.

Still, the profitability of our practice is gradually declining due to rising costs and flat reimbursement from the government and private insurers. Medicare cuts are on the horizon for our elderly patients. Initiatives from insurers and government to track quality are poised to drive up our overhead without any real pay increase to cover the extra expense.

Seeing more patients to increase revenue sometimes works against us. Instead of spreading our costs across more patient visits, every complex or high-risk patient we see drives up our liability insurance expenses, decreasing profitability. Yet, these are the patients who need care the most.

On a recent day in the office, I figure that 12 of the patients we saw could have been treated in a storefront clinic. I think it's time to beat the clinics or join them.

So, I'm hedging my bets and planning to open one in a small town about 20 miles from my main practice. I've been seeing patients in the same town about one day a week for 10 years by renting space in another doctor's.

Now I'm in the process of setting up a one-room office between two pharmacies on the same street. The rent will be $250 a month instead of the $2,500 month we pay each month for a full-service office. I plan to staff it with nurse practitioners from 8 a.m. to 8 p.m. weekdays and 10 a.m. to 4 p.m. on weekends. If they see more than 15 patients a day, we'll be in the black.
I think a retail clinic will have better operating margins than our office, especially with financial pressure mounting on traditional primary care practices. And I think it will help meet the needs of patients in the area. A storefront clinic won't solve all the problems facing our practice or the health-care system, but it could help prevent $600 earaches.

Due to his schedule and the volume of email he receives, Dr. Brewer may not be able to respond to all reader email. He does participate in his forum, where readers are urged to post. His email address is thedoctorsoffice@wsj.com

Tuesday, September 11, 2007

Read this for free now, but look at these ads...

Giving away medical information for free to sell advertising..... As a publisher myself looking at this from a business standpoint, this seems smart and interesting and a little risky. Critics will point to this as yet another example of the media being in bed with the drug companies. While it is an example of the two doing business, this model is also giving physicians free and easy access to medical information that they must pay for otherwise. Is wading through a few ads online or in their mailboxes -- e or snail-- worth it? Not sure, but the docs will weigh in on it by participating or not.

- WJ 9/11

From the NY Times............

September 10, 2007
A Medical Publisher’s Unusual Prescription: Online Ads
By MILT FREUDENHEIM
By some measures, the medical publishing world has met the advent of the Internet with a shrug, sticking to its time-honored revenue model of charging high subscription fees for specialized journals that often attract few, if any, advertisements.

But now Reed Elsevier, which publishes more than 400 medical and scientific journals, is trying an experiment that stands this model on its head. Over the weekend it introduced a Web portal, www.OncologySTAT.com, that gives doctors free access to the latest articles from 100 of its own pricey medical journals and that plans to sell advertisements against the content.

The new site asks oncologists to register their personal information. In exchange, it gives them immediate access to the latest cancer-related articles from Elsevier journals like The Lancet and Surgical Oncology. Prices for journals can run from hundreds to thousands of dollars a year.
Elsevier hopes to sign up 150,000 professional users within the next 12 months and to attract advertising and sponsorships, especially from pharmaceutical companies with cancer drugs to sell. The publisher also hopes to cash in on the site’s list of registered professionals, which it can sell to advertisers.

Mainstream publishers have wrestled for years with the question of how to charge for online content in a way that neither alienates potential readers nor cannibalizes their print properties. So far, few definitive answers have emerged. Reed Elsevier, which is based in London, is taking a risk that its readers will drop their paid subscriptions and switch allegiance to the new Web site, which will offer searches and full texts of the same content from the moment of publication.
“It’s a calculated risk, a bold step into the unknown,” said Dan Penny, a senior analyst in London at Outsell, a market research firm.

But Reed Elsevier executives hope that OncologySTAT.com users will be an attractive target for advertisers, providing a model for an array of portals they could set up for health care professionals. Future sites may focus on specialties like neurology, psychiatry, cardiology and infectious diseases, company officials said.

Monique Fayad, an Elsevier senior vice president, said the total online advertising market was growing “in double digits” and added, “We expect it will be a $1 billion opportunity within the next two years.”

In just the last two years, the number of visits by physicians to online medical journals increased 27 percent, while readers of the printed versions declined 14 percent, according to Manhattan Research, a health care market research firm.

OncologySTAT will compete in a crowded field that includes free online information at Medscape.com; PubMed.gov, a service of the National Institutes of Health; and the National Cancer Institute’s cancer.gov, as well as UpToDate.com, which supplies speedy authoritative answers to doctors’ queries for a fee.

Wayne T. Gattinella, chief executive of WebMD Health, said the potential for online drug advertising was still far from fully realized. WebMD offers free information across 30 medical specialties on its Medscape site, with growing support from drug companies.

But Mr. Gattinella said that only about 3 percent of pharmaceutical marketing dollars are spent online. Much more still goes to consumer advertising on television and to salespeople who visit doctors.

Although Elsevier’s medical and scientific journal business is profitable, revenue is flat and online readership is growing faster than print subscriptions. Reed Elsevier also owns LexisNexis, the online reference service, and trade publications like Variety; in July, the company sold its Harcourt textbook unit to Houghton Mifflin for $4 billion but kept the 500 journals it acquired from Harcourt in 2000.

The OncologySTAT site will give registered visitors limited access to other publishers’ journals, too. There will be free summaries, written by experts and updated weekly, of cancer-related articles from 25 other leading journals, like the Journal of the American Medical Association and The New England Journal of Medicine. Full texts of current articles in those non-Elsevier journals will still have to be bought until they become publicly available, typically in 6 to 12 months after publication.

The new Elsevier site’s target users include doctors like Dr. Peter Yi, a cancer specialist in Princeton, N.J. Like the vast majority of oncologists, Dr. Yi already logs in regularly. He searches the Internet for updates as he treats patients. He gets at least 10 e-mail messages a day about new drugs and other research, and he subscribes to five medical journals, which he can also read online.

Looking at OncologySTAT for the first time, Dr. Yi said he liked the features it offers, like chemotherapy regimens, conference reports, drug interactions and the ability to search by cancer type. “Having it all under one roof makes it easier,” he said.

But Dr. Leonard B. Saltz, a colon cancer expert at Memorial Sloan-Kettering Cancer, said, “Another Web site was not what we desperately need.” He added, “I know the literature of my area often before it is published.” Beyond that, he uses the government site, PubMed, and the Google Scholar search engine to drill into research issues.

Doctors like Dr. Saltz who work at the big teaching centers have free access to most, if not all, of the journals. But oncologists away from those centers, like Dr. Yi in Princeton, see 85 percent of all cancer patients and rely on the Internet as their link to the knowledge base.

Getting the relevant answers promptly may be more important to doctors than not having to pay for them, said Elizabeth W. Boehm, a principal analyst at Forrester Research.

“Anything that is going to save the physician time, without losing the certainty that they have seen everything that they need to see, is potentially valuable,” she said. “The question is, can they give them the information in a way that is more valuable, more easily searchable.”

Monday, September 3, 2007

HHhhhhmmmm

This raises some interesting questions regarding best practices within medical practices. Also from NY Times.....

Putting Pay on the Line to Improve Health Care
By MANOJ JAIN, M.D.
Published: September 4, 2007
Every quarter I get together with my partners to review the performance of our medical practice. Like a manager of a car dealership, I bring out the numbers. I show them how many patients we saw in the previous months, what we billed, how much we collected.

Yet too often we fail to answer some crucial questions: What is the quality of our care? How well or poorly are our patients doing? When it comes to those with pneumonia, for instance, did we deliver an appropriate antibiotic in a timely fashion? At the hospitals where we practice, is the mortality rate for congestive heart failure higher or lower than the national average?
Such statistics are easily obtained. Why are doctors so reluctant to look at them?
As a medical director for Medicare’s quality improvement organizations in Tennessee and Georgia, I can suggest several reasons.

First, most doctors are convinced that they take perfect care of their patients. But research tells us otherwise. A 2003 study in The New England Journal of Medicine found that 45 percent of Americans did not receive the recommended care, and a 1999 report from the Institute of Medicine suggested that preventable medical errors led to as many as 98,000 deaths a year.
Second, doctors tend to shrug off data reflecting poor performance, saying things like, “My patients are sicker than most” or “My patients don’t follow instructions.”

Third, the clinical quality data are often untabulated and unexamined, embedded in patient charts.

Finally, for many doctors there are no consequences for poor performance — no financial penalties from the insurers who pay most of the bills.

Unbeknownst to many busy physicians, this is all changing.

Under a federal law that took effect this summer, Medicare will pay doctors a 1.5 percent bonus incentive for reporting quality measures set out by a program called P.Q.R.I., for Physician Quality Reporting Initiative. This represents a significant step toward public reporting and pay for performance.

Hospital quality data is already being posted on Medicare’s Web site, www.hospitalcompare.hhs.gov. It is now easy to find out how a given hospital compares with the national average for death rates from common illnesses like heart attack, as well as the hospital’s performance on 21 quality measures (like giving aspirin and smoking-cessation advice to heart attack patients). Hospitals now receive incentives for reporting such data; soon their actual payments will be based on their performance on these measures.

Just as managed care swept the health system a decade ago and left its mark, so should this new policy, which Medicare calls value-based purchasing.

For my partners and me, it is eye-opening. Traditionally, our payments have been based on our resources (how much equipment we used) and volume (how many patients we saw). And so, in businesslike fashion, that is what we measured and how we tracked our performance. Soon, doctors will be paid according to quality and value. And our performance will be publicly reported on the Internet so our patients can choose the best doctors. With doctors’ reputation at stake, they will have an incentive to improve.

Though value-based purchasing sounds promising, such an approach has several potential land mines. Doctors will have an incentive to treat the less ill patients, because the outcome is bound to be better. Imagine the consequences if doctors cherry-pick patients on that basis. (Medicare does adjust its report cards for severity of illness, yet doctors are skeptical.)

Also, doctors already fed up with the bureaucracy and paperwork of Medicare may wash their hands of the program and refuse to see any Medicare patients, just as vast numbers of baby boomers begin turning 65 and entering the program.

How value-based purchasing will affect health care only time and human behavior will tell. But change is urgent for our misaligned health care system.

Manoj Jain is an infectious disease physician in Memphis.

Financing gimmicks for elective surgery

Can you also finance the extended warranty protection? I'm not real sure I like the idea of finance companies being involved in our health care system. -WJ

From the NY Times......

Doctors Offering No-Interest Loans to Patients
Aaron Houston for The New York Times
Nancy Schlachter paid for a $6,000 dental bill with an interest-free loan. Banks and insurers are offering more such financing.

Derrick Fields has $250 a month deducted from his bank account to pay for his laser eye surgery.

Zero-interest financing, a familiar sales incentive at car dealerships and furniture stores, has found its way to another big-ticket consumer market: doctors’ and dentists’ offices.

For $3,500 laser eye surgery, $6,000 ceramic tooth implants or other procedures not typically covered by insurance, millions of consumers have arranged financing through more than 100,000 doctors and dentists that offer a year or more of interest-free monthly payments.
Of course, going into debt to pay for medical procedures is nothing new for many people. And this type of financing is still only a fraction of the nation’s $900 billion market for consumer revolving credit.

But as the price of health care continues to rise and big lenders pursue new areas for growth, this type of medical financing has become one of the fastest-growing parts of consumer credit, led by lending giants like Capital One and Citigroup and the CareCredit unit of General Electric.
Big insurers, too, are devising new financing plans with various payback options. Upstart players have also aggressively cut deals with doctors.

The room for expansion looks ample, as rising deductibles, co-payments and other costs may force more of the nation’s 250 million people with health insurance to finance out-of-pocket expenses for even basic medical care.

“As more and more of the costs of care are shifted to consumers, people are going to need more credit,” said Red Gillen, a senior analyst at Celent, an insurance and banking research firm. “They are still going to need health care.”

The zero-interest plans are not for everyone. In fact, they are available only to the creditworthy — meaning they offer no help to those among the nation’s 47 million uninsured who are in difficult financial situations.

And creditworthiness is starting to be judged even more stringently, in light of the subprime mortgage crisis’s impact on the debt markets, according to David Robertson, publisher of The Nilson Report, a newsletter for the credit card industry.

Even for those who can get credit approval, the plans make sense only if users are able to make payments on time and close the loan on schedule, typically within 12 months. Otherwise, the loans after defaults can carry interest rates of 20 percent or more — similar to the default penalty on a typical credit card.

“We are very careful to tell patients upfront, ‘Be sure you can make your payments,’ ” said Dr. Richard J. Mercurio, a dentist in Lincroft, N.J. He arranges patient financing through the CareCredit unit of G.E., the leader in consumer medical financing.

Dr. Mercurio says he knows of at least two patients who missed payments and received monthly bills charging high interest rates. “They were not happy,” he said.

For those who are able to make their payments, though, the plans can make it possible to receive treatments that otherwise might be out of reach.

“There was no way I had $6,000 right out of my pocket,” said Nancy Schlachter, 40, who has dental insurance through her job as an accounts payable manager for a national construction company. She went to Dr. Mercurio for a series of dental procedures including a new crown, fillings and a tooth implant.

“The implant was very expensive, and it was not covered,” Ms. Schlachter said. But the dentist’s office arranged 12-month zero-interest financing. “It was the only way I could do it,” she said.

Some consumer debt experts warn that as more people try to bridge widening gaps in their health insurance, paying for medical care on credit could plunge the unwary into a financial crisis. In recent years, the use of high-interest credit cards to pay big medical bills has become a leading cause of consumer bankruptcy.

“Unless they are at risk of losing life or limb, people should be very cautious about putting medical bills on credit cards,” said Mark Rukavina, executive director of the Access Project, a research and consumer advocacy organization that helps people with their medical debts.
Still, consumer credit companies and some insurers are now experimenting with financing plans meant specifically for medical costs.

For people who think they could not pay off a zero-interest loan within a year, most credit companies also offer longer-term medical financing deals with 12 percent to 13 percent interest payable over several years. Those plans, though, must be arranged at the outset of the medical expense; a zero-interest plan typically cannot be converted to the longer-term program if consumers find themselves unable to pay off the one-year loans.

Some insurers, including UnitedHealthcare, also have special credit plans available for insured members whose policies are linked to health savings accounts. Such policies combine high-deductible insurance with tax-sheltered savings accounts where money can roll over year to year until needed for medical expenses. But typically, the amounts of money being set aside do not go very far toward meeting even routine health expenses.

So far, among the 1.76 million health savings accounts in this country, the average balance is $1,327, according to a recent survey by Inside Consumer-Directed Care, a trade publication. To help people with health savings accounts meet the shortfall, the Exante Bank unit of UnitedHealth Group is trying out a card that extends credit at rates currently averaging about 10 percent to 13 percent, depending on the applicant’s credit history.

UnitedHealthcare is also testing a medical credit card that would offer reduced rates.
“There’s a place for credit solutions that are integrated within traditional health insurance programs, when an individual hits that out-of-pocket expense,” said Tom Beauregard, a senior vice president at UnitedHealthcare. “The key is to make it voluntary, to make it simple and to offer favorable credit terms.”

As for the zero-interest deals, the credit providers say that most of them end up being just that — interest-free. About 80 percent of the medical loans that CareCredit provides are paid off on schedule and incur no finance charges, according to the company’s president, Michael J. Testa.
That, the companies say, justifies the high default interest rates for late payments, since that is the way they recoup the costs of doing business. In fact, though, the credit companies make money even on the interest-free deals, because they are typically keeping 10 percent of the fee the doctor charges the patient. On a $5,000 cosmetic nose operation, for instance, the plastic surgeon might receive only $4,500.

Another of the medical finance companies, HELPcard, says that for dentists whose customers are good credit risks, the lender’s commission might be only 4 percent to 5 percent. But for patients with low credit ratings, a dentist eager to build a clientele might have to accept as little as 75 percent of the bill, said Pat McGee, HELPcard’s senior vice president for sales and marketing.

The CareCredit unit of G.E., too, has special deals for patients whose credit is not well established. Stephanie Waterman, a coordinator for Dello Russo Laser Vision, a laser-surgery practice with offices in New York and Bergenfield, N.J., said patients deemed less creditworthy were required to pay $600 in cash and to agree to have 12 months of zero-interest payments taken directly from their bank accounts.

One Dello Russo patient, Senior Airman Derrick Fields, 31, stationed at Dover Air Force Base in Delaware, said that in June he paid $600 down on a $3,500 surgery bill for both eyes — a reduced charge the practice offers to members of the military.

“They take about $250 a month from my bank account,” said Mr. Fields, who said he soon expected to not wear eyeglasses for the first time since the second grade. “I owe $2,900.”
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