Employment Arrangements for Emergency Physicians

I meet once a month for breakfast with our EM residents. I learned this from my mentor, David Wagner, who started it well after I was no longer his resident and was serving on his faculty. I know the residents loved having his ear for an hour and there was a lot of give and take. I've been doing this now for five years and our sessions have never had much give and take. The ground rules for the hour are that I have to be able to act on information that I hear, but that nothing I hear will be attributed to the individual. Sometimes more is said than other times, but last year it finally occurred to me that some structure might be useful, particularly if focused around content not usually part of the core residency educational program. While all residents get some exposure to administrative topics, it seemed logical to focus more on these areas.

So as with many things, "Breakfast with the Chair" at my shop in 2008 has become more structured than what I fantasize Dave's were, back in the day. I'm using these sessions to talk to the residents about "life, the Universe and everything." Or at least to discuss some of the basics of selecting life, disability, travel and other sorts of insurance and what's on every senior resident's mind at this time of year: getting a job.

Tomorrow morning I'll discuss the various models of employment offering complete descriptions and trying to avoid judgments, though commenting on the strengths and pitfalls of each as I understand these. On the list will be the following:

• Hospital Employed



• Corporation Employed including single owners, small and large ownership groups, publicly traded corporations



• Independent Contractor models with and without your own Professional Corporation



• Locum Tenens



• Democratic Group grant/earn-in/buy-in models

I'm going to point them to this page with the suggestion that they pose their comments and questions here, too.

Farad Johnmar Discusses Health 2.0: Fad or Fundamental?

Fard Johnmar at HealthcareVOX nicely summarizes and explores some of the concerns I've been feeling as I've vacillated over attending the Health 2.0 Conference next month in San Francisco. I do think the fundamental concept is valuable, I'm concerned by the sound of hype inherent in the term: language does create its own reality. Nonetheless, I'm headed for San Francisco for the conference on my way to Chicago (I'm starting from Brooklyn, NY) for the annual ACEP Scientific Assembly.

I'd like to suggest that consistent with his theme, he could sharpen both his diagram of the four "clogged arteries" and his explanation of its content. First the diagram itself could benefit from the third dimension, I envision a cone the base covering the entire diagram and drawing to a point at a figure/avatar representing the user-consumer-patient-community of users.

I suggest this blanketing user-consumer-patient-community of users input not to hold this central aspect (We used to call it "patient-centered" and "family-centered" care.) outside or orthagonal to the concept embedded into the diagram, but rather to respect the underlying thoughts while refining the concept. For I see in all four of the "clogged arteries" components of purely professional endeavor and components of professional interaction with user-consumer-community of users.

Medical Decisions seems especially fraught. Perhaps that's just me, a physician-educator-executive, responding to the term in this context when my efforts over the past 30+ years in this realm are best crystallized by Jerome Groopman in How Doctors Think where the focus is really on how doctors make medical decisions. The user-consumer-patient-community of users certainly does as well, differently and at many different levels. Johnmar in conflating physician prescription practice with managing end-of-life care cost rather crosses many more boundaries than I can comfortably traverse within the core concept--at least so long as I'm devoting the attention I am to young physicians learning the practice of making medical decisions.

The implications of Molly Coye's (HealthTech) observation that hospital expenditures are shifting away from labor expenditures and towards capital, both facility and technological, seems fundamental to this transition time as well. I don't know if any hospital has asked its community if the user-consumer-patient-community of users would prefer a new MRI machine or a patient navigator program. Both is too glib an answer, which while not unrealistic today in many environments, may soon become so.

The exposure to these various constructs is provocative and mind-expanding. I'm looking forward to meeting some of the progenitors of the Health 2.0 concepts and the entrepreneurs who are seeking to bring it to fruition. There has to be a pony in there somewhere.

Certifying Commission for Health Information Technology (CCHIT) and the Personal Health Record (PHR)

Yesterday I received notice of the CCHIT's next steps in certifying PHRs. The message was broadly addressed, I'm sure the entire CCHIT mailing list received it. Note the request for help in spreading the word. It's somewhat ironic that this organization--with which I participate as an ED Workgroup member--whose mission is "to accelerate the adoption of health information technology by creating an efficient, credible and sustainable certification program" seeks to speak to consumers through its marketing director.

I guess this calls for redoubling my own efforts from the inside.

---

Today we are launching a program to increase the consumer participation in our personal health record (PHR) certification program development. And we could really use your help in spreading the word. If your organization has a communication channel to consumers, we would really appreciate it if you could carry the included information to them. I have attached a Word and PDF version of our invitation for your use (editor note: Same content as this post.) I would be happy to expand on this if you need more or customize it for your use if that would help.

We have several new activities in which consumers can participate:

·         The Commission has completed its first step, the creation of draft criteria for testing PHRs. Beginning Monday, Sept. 29, the criteria will be posted to http://cchit.org/participate/public-comment/  and available for a 30-day public comment period.

·         A new Web site and blog dedicated to furthering the conversation about PHRs, www.phrdecisions.com, will launch on that same date.  A consumer’s guide to certification of PHRs will also be available there. 

·         On Friday, Oct. 10, the Certification Commission will host a special free Town Call teleconference that will allow consumers and consumer representatives to gain a better understanding of PHR certification and how they can play a role in the process. The Town Call will include a presentation by Dr. Mark Leavitt, chair of the Commission, and Dr. Jodi Pettit, the staff leader of the PHR Work Group. It can be downloaded by Oct. 9 at www.phrdecisions.com.

Participants in the Town Call can ask questions during the call or online at www.phrdecisions.com. The questions and answers will be posted online following the teleconference.

The dial-in information for the Town Call is:
4:00 pm ET/ 3:00 pm CT/ 2:00 pm MT/ 1:00 pm PT

Participant Dial-In Number: 1 (877) 313-5342
Conference ID Number: 65204557

C Sue Reber

Marketing Director, CCHIT

Certification Commission for Healthcare Information Technology

503.288.5876 office | 503.703.0813 cell | 503.287.4613 fax

sreber@cchit.org

Is it time to drag private physicians out of the paper age?

Editorial

Our Pen-and-Paper Doctors 

Published: June 24, 2008 

If this country does not accelerate the conversion from paper to electronic health records, many health care reform promises will become irrelevant. 

Yes. So? 

American physicians are still paid on piece-work; productivity matters to them and their families. Seeing patients pays the mortgage and feeds the family. 

I've successfully implemented an electronic medical record that has served more than one-half million patients since 2002, yet I know that we've accomplished this only by sacrificing physician productivity even as we've improved overall productivity in our emergency department. Optimizing an entire system often requires that components of the system operate at less than optimum in some fashion. 

We can do this at my hospital because our physician staff is only partially compensated by piece-work and the alternative subsidies could be adjusted. 

The NY Times got it wrong this time. Private physicians behave as they do in response to the totally distorted payment system--even the term "reimbursement" so common in this context is evidence of this distortion. 

My Dad, an internist, used to say that the head-bone is connected to the foot-bone. He practiced internal medicine and gastroenterology and empirically experienced connectedness of the head-bone and the gut long before we had the science proving it. 

It's not the private physicians who must be dragged out of the paper age. It's the payment system and the financing of healthcare in 21st century America. 

The NY Times should castigate our policymakers, not our practitioners.

Mobile Lawyer and "ER" the TV show

ER: Season 11, Episode 177861, 1/20/2005

[ . . . ]

A personal injury lawyer sets up a mobile office outside the ER, infuriating Lewis as he tries to turn dissatisfied patients into clients.

[ . . . ]

It turns out that the post on the Mobile Lawyer who showed up at our hospital and ER last spring caught some notice in the blogosphere. Overlawyered picked up the post and I had thousands of hits in a few days. A colleague referred another contact and somehow the story reached the writing staff at the ER production company to appear in the fictionalized version on tomorrow's show. Imagine that.

Could CMS demand only delayed reads of imaging studies and take Ultrasound billing away from EM?

An Influential Federal advisory panel has voted to recommend lower 2006 Medicare payments than expected by physicians and hospitals, as well as other policy actions affecting both. (emphasis added)

While reimbursement levels are a concern, it's the other "policy proposals" that really scare me.

The Medicare Payment Advisory Commission voted to recommend a 2.7 percent increase in Medicare payments to doctors, which is less than the expected increase in doctors' costs, but substantially more than doctors would get under current law, under which payments would be cut five percent next year if Congress takes no action, reported the New York Times.

[. . . ]

The commission expressed concern about the proliferation of imaging equipment and services in doctors' offices, and urged Congress to direct the secretary of health and human services to set national standards for doctors who perform or interpret diagnostic imaging studies billed to Medicare - a move which would alter the historical role of states and medical specialty boards in physician licensing and certification, the Times noted. The standards would cover the training and education of doctors who bill Medicare for X-rays, CAT scans, PET scans, magnetic resonance imaging, ultrasound, (emphasis added) echocardiography and other imaging. The panel maintained that poor quality diagnostic imaging can lead to repeat tests, misdiagnoses and improper treatment, the Times added.

[. . . ]

So this proposal could entrench delayed reads as the standard for all radiography as a consequence of the requirement that only those meeting federal standards for "training and education" interpreted imaging studies. Also CMS could easily decide that bedside ultrasound imaging was merely a component of the evaluation and management (E&M) service and not separately compensable.

http://www.nytimes.com/2005/01/18/politics/18medicare.html?oref=login&pagewanted=print&position=

WSJ.com - California Hospitals Open Books, Showing Huge Price Differences

Link: WSJ.com - California Hospitals Open Books, Showing Huge Price Differences. (subscription required)

A new law in California mandates that hospitals there do what few hospitals in America will: open up their "chargemasters," books that show thousands of list prices for medical goods and services. An examination of chargemasters at several hospitals shows that pricing strategies fluctuate wildly -- on everything from brain scans to painkillers to leeches. Depending on a hospital's pricing method, the charge for the same commodity or service, such as a blood test, can vary by as much as 17-fold from one institution to another.

Horrors! People will now learn that the respected institution in their community, "their hospital" behaves entirely irrationally in order to make a buck. There's merit to exposing this and other practices to daylight, but the real irrationality derives from the continuing skirmishes and overall lack of coherent information about what it takes to make a successful hospital work and serve its community. (I'll leave the justification for what it takes to serve hospital company investors for others to explain.