Reasons To and To Not

As Endeavor Health is a management consulting firm, the title of this blog post may not appear too shocking, but let’s be fair and start off with why not to hire a consultant.

Consultants aren’t magicians. You shouldn’t seek a consultant if your product or service doesn’t make sense. You shouldn't expect a consultant to swoop in and secure more patients if you don’t have a methodology that allows you to stand out. And finally, don’t hire a consultant so you can abdicate the all-important role of marketing to an “expert.”

A truly great consultant won’t accept your money unless they believe they can actually help you and, no matter what you believe your burning need is, a competent consultant should always evaluate the client before considering engaging in the relationship. 

Here are just a few areas that should be considered by a prospective consultant:

YOU NEED A REAL STRATEGY

A great consultant will demand that you spend time building a firm foundation based on strategy before proposing a series of tactics aimed at lifting patient numbers. Until you’ve found fa way to change the context of how your ideal patient views your practice, in effect rendering the competition irrelevant, you’ll find that your marketing efforts will never build momentum.

YOU NEED FEWER OBJECTIVES

A great consultant will help you determine your highest payoff work and your most pressing objectives based on where you want to be in a year, in three years, in five years – not next week. And, a great consultant will make sure that the number of priority objectives at any given time stays very, very small.

YOU HAVE RESOURCE GAPS

Sometimes in the “do it all yourself” world of a single provider practice it’s difficult to spot the areas that require outside help. You may be able to set up your newsletter, add plugins to WordPress and clumsily create header graphics for your social media profiles, but is this work actually robbing you from focus on higher payoff work.

Sure, some of these things may need to be attended to, but a great consultant will help you stop doing the things that are better handled by others. In fact, they might just help you once again take control of your practice.

YOU NEED TO FIX YOUR CONVERSION

This may be our favorite!? Too many medical and dental practice owners, and sadly some “consultants”, focus on traffic and likes when the highest priority should be conversion. When you can figure out how to get prospective patients to your website and those prospects then respond to your presentation by making appointments you can build a significant and successful practice!

Once you have conversion trending upwards you can then buy traffic confident in the fact that you can bank on conversions.

YOU CAN’T STAY FOCUSED

One of the dirty little secrets of consulting is that a significant part of you simply needs someone to hold you accountable – someone to help you document your goals and objectives and then whack you with some sort of a stick when you wander off into new ideas and social networks, because staying focused seems way too boring.

A part of this is accomplished through constant review(s) and monitoring and hard appointments, but the greatest gains are achieved when your focus starts to produce results! A great consultant will demand metrics tied to objectives and help you process and understand to overarching value you’ll derive by hitting your goals.

Okay, now you can go and check email and play around on Facebook for a bit, but tomorrow it’s back to rocking practice goals! #weshouldtalk.

Or...Managing Your Practice

It Truly Is As Simple As Effective Management!

Success in dentistry depends on the ability to properly manage both the clinical and practice management aspects of your practice. And, when it comes to dental practice financials, there are a number of moving parts one has to pay attention to - income, fees, overhead, taxes, insurance reimbursements, payroll, etc. Because, even if you’re the best dentist in town - spending incredible amounts of time and money on improving your clinical skills - if you don’t manage your money, you’re not going to be able to build and maintain a profitable, financially sustainable practice.

Fact is, patients don’t respond only to clinical skills! In fact, most patients cannot differentiate between a dentist who has taken 1,000 hours of continuing education in the past year and a dentist who has taken only 20. Majority of dental patients will never know if they've received inferior treatment unless they are informed by another dentist.

Advancing your practice management skills along with your clinical training is essential to growing a successful dental practice! Every decision that you make on a clinical product, technique, or piece of equipment has direct practice management ramifications on things like patient satisfaction, efficiency, and overhead control. Similarly, every practice management decision will have direct clinical applications as well. 

It is this constant balance of clinical and practice management skills that you need to hone and improve that will dramatically enhance your ability to diagnose and treat patients while at the same time motivating and leading patients to optimal dental health while "managing" the most important aspect of the practice management...profitability!

Enter The Consultant!

When vetting prospective dental clients and assessing current financial practices of the dentist, EHM most frequently finds three factors omnipresent:

  • Failing to operate within net
  • Failing to pay themselves a salary - more often taking "draws", "disbursements" or "distributions" 
  • Using the practice as their personal ATM

Few dentists are financial experts — so how can they be expected to know how to manage their money in the most efficient way possible? Hiring an expert such as a seasoned management consultancy is especially important to help create financial benchmarks and pathways with which to achieve financial success. Of the dentist's EHM engages, the main action they seek for managing their practice’s finances is hiring a firm with financial experience, preferably one with specific dental practice expertise.

One caveat here is that the "expert" you hire should not be your buddy, or the "local marketing girl" who meets weekly with you and your peers for cocktails and appetizers. What you end up with here is not a financial adviser, but "friends" selling you fun.

Outside of a management consultant, EHM recommends a few essentials to assist with optimizing your dental practice:

1. Dental Practice Management Software

Even if you have an accountant to advise you on financial matters, you still need to give them the hard data they need to assess your practice’s finances. Using the right software, you can easily track expenses, revenues, and other financial information to provide your accountant with an accurate view of your income and outcome.

Depending on the PM software you use, it may have its own accounting features, or it may integrate with other accounting software such as QuickBooks.

2. Track Important Practice Metrics

Stay on top of your day-to-day and month-to-month financials by tracking important business metrics that affect your profits. One of the most crucial pieces of data to pay attention to is your P&L (profit and loss statements)! 

Some of the other smaller data pieces that go affect your P&L (and which you should also pay attention to) are as follows:

Fixed expenses — Expenses that do not change month to month (utility bills, rent/mortgage, loan payments, etc.)

Variable expenses —Expenses that may change based on your monthly production (lab bills, supply bills, staff pay, etc.)

Over-the-counter (OTC) collections  - OTC collections should be 45% to 55% for fee-for-service practices. 

Patient stats — This include new patients per month, number of patients seen each day, and cancelation rate

Treatment presented vs. treatment accepted ratio - atio of treatment presented vs. treatment accepted should be 70-90%.

Number of new inquiries vs. number of new appointments scheduled - Average practice may lose as much as 10% of its patient base through normal attrition — aim for 15% new patient growth to offset this.

Ratio of perio production vs. overall hygiene production - Perio/hygiene production should be at least 30% perio services.

Doctor production per hour - EHM average dental client production per hour is $425 with about 18% achieving over $550 per hour.

Hygiene production per hour - verage hygiene production per hour is about $121

Unscheduled time units - Monitoring production vs. payroll hours provides a wealth of information as labor represents one of your largest financial liabilities   

Accounts receivable - Collection should be at 97-99% with less than $2,500 at 90 days

3. Set Realistic Fees and Salaries

Fee schedule and salaries are some critical factors affecting your dental practice’s revenues. Fees are usually calculated by fee averages for the area and based on insurance reimbursement rates for fees. Salaries are based largely on the going rate in your area as well.

With regard to setting fees, many fee-for-service dental practices establish fees based on what is the "going-rate" in their service area. Problem here is, what Dr. Jones charges doesn't really factor into your bottom line - your overhead may be twice that of Dr. Jones and his lower fees won't pay your bills! Being the lowest in your area is akin entering a race to the bottom. EHM can help you establish the appropriate fees and salaries for your practice.

4. Invest in things that increase your revenue

"You have to spend money to make money". Yep, the old adage is indeed accurate! But, when it comes to running a practice, what things do you need to spend money on in order to optimize revenues?

  •  Make patients happy, and
  •  Boost practice visibility, both online and off

Specific advice in this area:

  • Form relationships with repeat patients by offering them discounts on some services may generate referrals.
  • Participate in charity events in the community, volunteering, etc. People will notice you and come to your practice as a result.
  • Invest in technology and facility improvements.
  • Invest in quality staff — caring, qualified dentists and staff that truly connect to patients make them feel valued and respected.
  • Effective marketing campaigns

5. Controlling Overhead 

It may seem like a no-brainer, but many dental practices often neglect to save money. Interested in the latest digital scanner for your practice...need a new autoclave or server? What about your retirement?

Is your dental practice on track for financial success in 2018 #weshouldtalk

Is Your Practice In Their Cart

Four Essential Practice Management Strategies To Fine Tune Your Practice

Our recent recession has been a game-changer for the likes of many a medical, dental and chiropractic practice! Endeavor Health Management research indicates that 42% of practices have suffered revenue declines over the last four years. And, even now as the economy improves, many practices are struggling to regain previous levels of practice production/revenue and doctor income. 

It has become apparent that we have entered a new era of practice management. What worked in the past may not work now. While it remains possible for providers to grow their practices, they need effective business skills and systems to reach the highest levels of success.

Prior to the recession, the majority of practices could be relatively successful without either excellent business systems or strong leadership. This was largely due to supply and demand. Patients were abundant. Most of them kept their appointments and accepted recommended treatment, especially for need-based care.

Now, however, there are fewer patients, more canceled appointments and no-shows, and most disturbing...decreased case acceptance for most all services. To navigate this changing  landscape, providers need to manage their practices based on core business principles.

Growing your practice in today's economy requires some level of business acumen. Understanding and properly implementing a successful profit-making strategy is key to a well-functioning practice! Here are four requisite overarching strategies for creating your conceptual framework:

1. Manage overhead

Endeavor Health Management recommends an overhead target of 59% for general practices. Every percentage point over 59% costs practices thousands of dollars. For example, if a medical practice is producing $700,000 per month with 65% overhead, that's $42,000 in excess overhead per month. For a practice with a 75% overhead, that would be $112,000 in excess overhead per month...that's over $1.3m per year! Even if a practice is just a few points above 59%, it still has opportunities to increase income by thousands of dollars. Optimizing overhead requires a comprehensive approach, including these action steps:

• Follow the money - Keep track of collections, purchases, and expenses - from staff salaries to supplies. Record how much the practice spends in each category every month. Measure expenditures against past costs to see if they are increasing, decreasing, or staying the same.

• Track inventory - Practices should take inventory semiannually. This will help offices maintain a steady stream of supplies, avoid overages and shortages, and have greater control over expenses. Automated inventory management software is an optimal solution for managing practice inventory!

• Examine insurance participation - Practices should analyze patient insurance participation each year. Providers should be aware of important data such as what percentage of total practice collections is generated by insurance, which insurance plans pay the highest reimbursement rates, which ones pay the lowest, what plans are provided by local employers, etc. This information will help doctors make the best decisions regarding insurance participation.

2. Control collections

Practices should get paid for the services they provide. In many dental offices for example, teams are uncomfortable asking for payment. And, while their medical counterparts rarely have issue collecting copays and deductibles over-the-counter, dental practices continue to struggle to this end. Like a medical office, a dental office is obviously a place where dental care is provided, and it is also a business that requires payment for services rendered, so dentists can continue to provide high-quality care to patients.

To this end, failing to collection "over-the-counter" responsibilities creates overdue accounts receivable, which have become more prevalent for many practices in the post-recession economy. These receivables cost the practice in several ways. First, there is the issue of not being paid for services already performed. Second, the office must use team members to track down this revenue when they could be performing more productive tasks. Third, it may never be collected. The best way to reduce collections is to have patients pay at the time of service!

Endeavor Health Management closely works with clients to realize a collections target of 99%. In a sluggish economy, patients may be slower to pay their bills. Practices need clear financial policies that the team communicates to patients using a method such as a scripted "Value Creation" treatment plan. Utilizing a script as an essential communications tool, information about financial policies can be properly conveyed to patients, and copay and deductible expectations can be presented with better clarity.

Creating a strategic treatment planning model will increase practice revenue(s) by offering patients' options for treatment, if there are any, and options for payment, which there always are...cash, check, credit cards, and outside financing. Giving patients choices makes treatment more affordable and full payment easier!

3. Replace outdated management and marketing systems

Outdated processes create bottlenecks in a practice's systems. Left unchecked, outdated and inefficient processes will hinder productivity and ratchet up stress on the doctor and team. During a good economy, practices will often put up with outdated systems because the schedule is filled with patients. However, a weak economy exposes vulnerabilities in old systems. Without strong management and internal marketing systems in place, practices will find it nearly impossible to grow in today's economy.

Effective systems have the power to transform an underperforming practice into a high-performance business. Management and internal marketing systems are the foundations upon which the provider builds practice success year after year. If that foundation is poorly constructed, practice success will be short-lived, difficult to achieve, or nonexistent.

To avoid lost productivity and production plateaus, practices should replace their management and internal marketing systems every five years. The following steps will help practices redesign their systems:

• Collect all necessary data to understand each practice system.

• Use all collected data to develop ideal models based on the unique needs of your practice.

• Customize all ideal models to fit the goals of the doctor and team.

• Implement new systems to increase production.

• Measure results to ensure that the new customized model is on track to achieve all practice goals.

Depending on how old (and inefficient) the systems are, it can require up to a year to completely replace all systems without disrupting daily operations or causing excessive stress on the team. Likewise, receiving expert guidance from trusted advisors can shorten the amount of time needed to develop and implement high-performance systems. To build a highly successful practice, all major systems must be addressed and inefficiencies that slow down systems removed.

4. Attract and retain patients

Current patients are the backbone of the practice and often serve as a source for new patients. In today's economy, patients are more likely to cancel or not show up unless value is built for the treatment and appointment. Endeavor Health Manaagement recommends a variety of patient-retention strategies to keep patients coming to the practice:

• Schedule the next appointment in advance. For dental practices, the hygiene department provides a steady stream of patients and production - 82% of hygiene patients should move to treatment. Patients should visit the practice every six months for recare. The best way to achieve that objective is to schedule the next appointment before they leave your office.

• Confirm all appointments 48 hours in advance. Practices should not rely on home phone numbers. Use modern communication vehicles, including email, text messages, and especially cell phone numbers.

• Provide superior customer service. The goal should be to exceed expectations during every patient interaction. Don't give patients a reason to not come to your office.

Quality customer service also encourages patients to talk about the practice to friends and family members. Remember, current patients are the best source for new patients. When patients are "wowed" by high quality care and great customer service, they will gladly refer their friends, family members, and neighbors if a scientific internal marketing program is in place. Team members should be trained to ask for referrals and testimonials from satisfied patients. Any patient who refers someone should receive a handwritten thank you note and phone call from the doctor.

Engineer your own comeback

Even in the current economy, providers can still grow their practices exponentially. These four core business principles can help you effectively manage your practice, reduce costs, and increase production. Providers can no longer wait for an economic turnaround - they have to engineer their own comeback.

How's your practice performing? #weshouldtalk

Creating a Predictive Marketing Strategy

"Hope" is NOT a Marketing Strategy!!

Today's agile dental practices implement certain marketing strategies, whether they are adding to their product/service line or adding new distribution channels. When marketing managers implement marketing strategies on their own volition, they are using proactive marketing. However, if some dynamic occurs in the dental industry like a competitive price change or the introduction of new technology (i.e., in-house dental mills, diode lasers, etc.) marketing professionals may need to use reactive marketing to ward off potential negative effects on their production and profits.

Significance

In reality, most dental practices use a combination of both proactive and reactive marketing. Proactive marketing is highly common when a product or procedure is new, because there is little or no competition. The bellwether provider entering the industry is making all of the marketing decisions or being proactive. However, because of its success, competitors gradually enter the market, mostly following similar plans of action. Consequently, the reactive marketing is on the part of the new competitors.

Effects

Over time, as the product/procedure becomes established, the industry leader occasionally needs to change his/her marketing strategy as more competitors become established providers in the delivery of the product/procedure. For example, one provider may be trying to establish itself as the service leader, increasing its dental implant offerings. Astute marketers for the industry leader expect some of these moves in advance, and are more proactive in expanding their own production capacity. Then the industry leader eventually needs to employ various reactive marketing strategies, especially if competing providers try to target the leader's patients.

Identification

Besides competition, there are other factors that influence whether a provider needs to be more proactive or reactive with his/her marketing. The economy can have an impact on a practice's marketing decisions. For example, a prolix (drawn out) recession may force a small, single practitioner office of premium and high-priced cosmetic dentistry to lower prices, a reactive marketing move. Additionally, a practice's advertising may be deemed by regulatory officials to be misleading, which forces the provider to change his/her advertising, a reactive marketing decision. Contrarily, a sudden influx of available resources may enable a provider to lower his/her prices, a proactive marketing move. Other factors that can influence proactive and reactive marketing decisions include regulatory, UCR, and technological changes.

Considerations

There are times when patient's actions can force a practice from more proactive marketing to reactive marketing. For example, a strong oral health movement can particularly affect the sales and profits of small dental practices that rely on SRP, fillings, and other restorative procedures. As a reactive marketing strategy, a provider may need to consider moving away from a fee-for-service model to an insurance dependent practice model. Eventually, when industry changes have settled, a practice can resume a more proactive marketing strategy to attract patients.

Prevention/Solution

Providers hoping to increase their amount of proactive marketing relative to reactive marketing should engage a consultant familiar with markets, trends, and emerging best practices in regulatory affairs, reimbursement strategies and the latest diagnostic and treatment methods; a firm with the bandwidth capable of understanding your institutional context, sector dynamics, and macroeconomic environments. Performing a combination of industry study through secondary research reports and conducting patient satisfaction surveys will keep you well-informed about your particular niche' and patient needs.

Not sure if your practice is reacting to your competition? #weshouldtalk

Waive...Collect...Write-Off...

Think About It...Then Think Again!!

Physicians and dentists sometimes waive patients' cost‐sharing amounts (e.g., copays or deductibles) as an accommodation to the patient, professional courtesy, employee benefit, and/or a marketing ploy; however, doing so may violate fraud and abuse laws and/or payor contracts. From a payor's perspective, waiving cost‐sharing amounts creates two problems. First, payors often contract with providers to pay based in part on the provider's usual charges. The Office of Inspector General (“OIG”) has argued that a provider who routinely waives copays is misrepresenting its actual charges. Second, and more importantly, payors require copays to discourage overutilization and reduce costs.

Waiving copays and deductibles removes the disincentive for utilization, thereby potentially increasing payor costs. Accordingly, federal and state laws as well as payor contracts generally prohibit waiving cost‐sharing absent genuine financial hardship.

Federal Programs. Waiving copays and deductibles for government program beneficiaries implicates at least the following laws:

1. Monetary Penalties Law. The federal Civil Monetary Penalties Law ("CMPL") prohibit offering or transferring remuneration to federal program beneficiaries if the provider knows or should know that the remuneration is likely to influence the beneficiary to order or receive items or services payable by federal or state healthcare programs (e.g., Medicare) from a particular provider. (42 USC 1320a‐7a(a)(5)). Violations may result in penalties of $10,000 per item or service provided, treble damages, repayment of amounts paid, and exclusion from federal programs. (Id.; 42 CFR 1003.102).

The CMPL specifically defines "remuneration" to include waivers of copays and deductibles. (42 USC 1320a‐7a(i)).

2. Anti‐Kickback Statute. The federal Anti‐Kickback Statute ("AKS") prohibits knowingly and willfully offering, paying, soliciting or receiving remuneration to any person to induce such person to order or receive any items or service for which payment may be made under a federal healthcare program unless the arrangement fits within a regulatory safe harbor. (42 USC 1390a‐7b(b)). The AKS is violated if "one purpose" of the remuneration is to induce federal program business. (United States v. Greber, 760 F.2d 68 (3rd Cir. 1985)). Violations may result in a five year prison term, $25,000 criminal penalty, $50,000 administrative penalty, treble damages, and exclusion from Medicare and Medicaid.

(Id.; 42 CFR 1003.102). The Affordable Care Act also made an AKS violation an automatic violation of the False Claims Act, which may result in additional penalties of $5,500 to $11,000 per claim submitted, and repayment of amounts improperly received. (42 USC 1320a‐7a(a)(7); 42 CFR 1003.102). The Office of Inspector General ("OIG") has interpreted the Anti‐Kickback Statute to apply to waiving patient cost‐sharing amounts if "one purpose" of the waiver is to induce or reward federal program business, a difficult standard to defend against. (OIG, Special Fraud Alert: Routine Waivers of Copayments or Deductibles under Medicare Part B (May 1991)). The OIG has specifically warned against the following practices:

 Advertisements which state, “Medicare Accepted as Payment in Full”, “Insurance Accepted as Payment in Full,” or “No Out‐of‐Pocket Expenses.”

 Advertisements which promise that “discounts” will be given to Medicare beneficiaries.

 Routine use of “financial hardship” forms which state that the beneficiary is unable to pay the coinsurance/deductible (i.e., there is no good faith attempt to determine the beneficiary’s actual financial condition).

 Collection of copayments and deductibles only where the beneficiary has Medicare supplemental insurance (“Medigap”) coverage (i.e., the items or services are “free” to the beneficiary).

 Charges to Medicare beneficiaries which are higher than those made to other persons for similar services and items (the higher charges offset the waiver of coinsurance.)

 Failure to collect copayments or deductibles for a specific group of Medicare patients for reasons unrelated to indigency (e.g., a supplier waives coinsurance or deductible for all patients from a particular hospital in order to get referrals).

 “Insurance programs” which cover copayments or deductibles only for items or services provided by the entity offering the insurance. The “insurance premium” paid by the beneficiary is insignificant and can be as low as $1 a month or even $1 a year. These premiums are not based upon actuarial risks, but instead are a sham used to disguise the routine waiver of copayments and deductibles.

(Id.).

3. Exception: Financial Hardship. The OIG has confirmed that it will not enforce the CMPLand AKS against providers who waive copays or deductibles due to genuine financial hardship. The CMPL specifically excludes from the definition of “remuneration” the waiver of copays and deductibles if all of the following conditions are satisfied:

(i) the waiver is not offered as part of any advertisement or solicitation;

(ii) the person does not routinely waive coinsurance or deductible amounts; and (iii) the person (I) waives the coinsurance and deductible amounts after determining in good faith that the individual is in financial need; or (II) fails to collect coinsurance or deductible amounts after making reasonable collection efforts.

(42 USC 1320a‐7a(i)). The AKS also contains an exception for cost‐sharing waivers for inpatient hospital services if certain conditions are satisfied (see 42 USC 1001.925(k)); however, even if this exception does not apply, the OIG has stated:

The Federal anti‐kickback statute does not prohibit discounts to uninsured patients who are unable to pay their hospital bills. However, the discounts may not be linked in any manner to the generation of business payable by a Federal health care program. Discounts offered to underinsured patients potentially raise a more significant concern under the anti‐kickback statute, and hospitals should exercise care to ensure that such discounts are not tied directly or indirectly to the furnishing of items or services payable by a Federal health care program.

(OIG, Hospital Discounts Offered to Patients Who Cannot Afford to Pay Their Hospital Bills (Feb. 2004)).

The OIG offered some direction for hospitals (and other providers) in determining and documenting financial need:

The OIG recognizes that what constitutes a good faith determination of "financial need" may vary depending on the individual patient's circumstances and that hospitals should have flexibility to take into account relevant variables. These factors may include, for example:

(i) the local cost of living;

(ii) a patient's income, assets, and expenses;

(iii) a patient's family size; and

(iv) the scope and extent of a patient's medical bills.

Hospitals should use a reasonable set of financial need guidelines that are based on objective criteria and appropriate for the applicable locality. The guidelines should be applied uniformly in all cases. While hospitals have flexibility in making the determination of financial need, we do not believe it is appropriate to apply inflated income guidelines that result in waivers for beneficiaries who are not in genuine financial need. Hospitals should consider that the financial status of a patient may change over time and should recheck a patient's eligibility at reasonable intervals sufficient to ensure that the patient remains in financial need.

For example, a patient who obtains outpatient hospital services several times a week would not need to be rechecked every visit. Hospitals should take reasonable measures to document their determinations of Medicare beneficiaries' financial need.

(Id.; see also OIG, Questions On Charges For The Uninsured (Feb. 17, 2004)).

Other Laws. In addition to the foregoing, waiving cost‐sharing amounts may violate other laws. For example, waiving copays and deductibles for referring physicians would usually establish a financial relationship that would trigger the federal Stark law unless the arrangement were structured to fit within a regulatory safe harbor, such as the “professional courtesy” exception. (See 42 USC 1395nn;

42 CFR 411.357(s)). Although States may also have their anti‐kickback statutes or laws prohibiting the waiver of copays or deductibles. For example, Idaho law states:

It is unlawful for a service provider to engage in a regular practice of waiving, rebating, giving, paying, or offering to waive, rebate, give or pay all or part of a claimant’s deductible or claim for casualty, disability insurance, worker’s compensation insurance, health insurance or property insurance.

(IC 41‐348). Other states may have similar statutes that apply to government programs and/or private pay programs.

Private Payors. In addition to relevant laws, private payor contracts generally require that the provider collect copays and deductibles. Failure to do so without the payor’s express approval would violate the contract terms and could result in claims for breach of contract or repayment.

Most payors likely would not complain if the provider could establish that it waived the cost‐sharing amount due to financial need, but to be safe, the provider may want to confirm same with the payor.

Next Steps. Healthcare providers should review and, if necessary, update their policies and practices and train their staff concerning waiver of copays and deductibles to ensure compliance. As appropriate, providers may want to work with their significant private payors to confirm the situations in which the provider would be allowed to forego collecting cost‐sharing amounts, such as documented financial hardship. Addressing the issue upfront may avoid costly repayments or adverse claims in the future.

If you are unsure whether your practice policies are within compliance #weshouldtalk

An Answer To Inoperability

Is Your Practice Prepared For The Upcoming World of Blockchaining?

The past several months, Blockchain technology has been making headlines everywhere. If you’ve recently attended any tech event there is a significant probability that you came out of them having heard just that bit more about it. Everybody is talking about blockchain--from the President Trump to the government of Estonia! Despite all the hype, for many people (across different industries) the blockchain concept still seems difficult to grasp, which makes it one of the most misunderstood technologies of 2017. The confusion around blockchain can be attributed both to its contentious origin (Satoshi Nakamoto, the “unknown” who designed Bitcoin and its original reference implementation) and equally to the absence of any clear and standard definition of blockchain technology. Nevertheless, the perceived (if not yet fully understood) disruptive nature of blockchain and its possible impact on business across industries makes it crucial first to understand blockchain and then to distinguish the hype from reality. Here, I’m going to attempt to unpack blockchain at a basic level and understand its implications for the healthcare industry.

What is blockchain technology, and how can we separate hype from reality?

So what is blockchain? Let’s begin by filtering out all the hype and technological jargon, blockchain technology is, at its simplest, a distributed and immutable (write once and read only) record of digital events that is shared peer to peer between different parties (networked database systems). In short, the fundamental strengths of a blockchain system are found in its data integrity and networked immutability. That said, there is always scope to build application layers atop a blockchain system and enable additional functionalities such as public or private keys, or self-executing mechanics (e.g. smart contracts), but this isn't the core functionality of blockchain technology.

To put it even more simply, let’s travel back to the 1990s, when “internet” was the buzzword. People misunderstood the internet with a tunnel vision around its early use cases (e.g. internet = email, or internet = Web). Likewise, today’s confusion around blockchain technology is not because of its fundamental properties at the protocol layer, but rather because of hype around as-yet-unproven use cases at the application level, which are often mistaken for the integral part of core blockchain technology. Today, an example would be that many people commonly identify blockchain with Bitcoin, far and away the most commonly known implementation of blockchain technology. But in fact Bitcoin is only the tip of the iceberg of several hundred applications using the blockchain system today.

Translating this analogy for the healthcare industry, the concept of blockchain technology and systems is undoubtedly disruptive, but it will not act as an end-all, be-all to solve emerging business problems in the fast-changing and highly interconnected digital health ecosystem. Rather, it will be an evolutionary journey for blockchain-based healthcare systems or applications, where trust and governance within a blockchain network or consortium will be the critical success factors for implementation.What are the most promising blockchain-based use cases for the healthcare industry?

Beyond blockchain technology’s utopian moment in the fintech industry, in the healthcare industry it has just started to inspire both relatively easily achievable and more speculative potential applications. Healthcare authorities, governments and the provider community globally (Yes, you physicians and dentists) are equally excited about the new possibilities presented by blockchain. Nevertheless, the industry needs to focus on establishing blockchain consortia to foster ecosystem partnerships and create standards or frameworks for future implementation on a large scale across healthcare use cases. The Hyperledger Foundation, an open-source global collaborative effort created to advance cross-industry blockchain technologies, is one of the best examples among many developing small blockchain consortia models in the healthcare space.

Despite the current euphoria, it’s important to understand and decode the hype cycle for blockchain technology and its realistic healthcare applications. By doing so, we believe that, among several hundred use cases, the five blockchain-based healthcare use cases mentioned below demonstrate more convincing opportunities, albeit at varying degrees of adoption across countries and health systems.

Clinical Health Data Exchange and Interoperability: 

When we talk about blockchain and healthcare, data exchange is typically the first topic to come up. Blockchain-enabled health IT systems that can provide technological solutions to many challenges, including health data interoperability, integrity and security, portable user-owned data and other areas. Most fundamentally, blockchain could enable data exchange systems that are cryptographically secured and irrevocable. This would enable seamless access to historic and real-time patient data, while eliminating the burden and cost of data reconciliation. The recent collaboration between Guardtime, the data-centric security company, and the Estonian eHealth Foundation to secure the health records of one million Estonian citizens using its proprietary Keyless Signature Infrastructure (KSI) is a classic example of blockchain technology. However, considering the complexities around data ownership and governance structure for health data exchange between public and private entities, it would be difficult to replicate the Estonian blockchain-secured health records model globally.

Claims Adjudication and Billing Management: 

An estimated 5-10% of healthcare costs are fraudulent, resulting from excessive billing or billing for non-performed services. For example, in the United States alone, Medicare fraud caused around $30 million in losses in 2016. Blockchain-based systems can provide realistic solutions for minimizing these medical billing-related frauds. By automating the majority of claim adjudication and payment processing activities, blockchain systems could help to eliminate the need for intermediaries and reduce the administrative costs and time for providers and payers. Blockchain could also have significant ramifications for improving some of the huge logistical information tracking hurdles of reliability-centered maintenance (RCM) functions. Recently, CMS announced interest in utilizing blockchain technology in place of the standardized TPE to perform beta “probes” into the fairly new field of dental sleep medicine to develop blockchain-based healthcare claims management solutions.

Drug Supply Chain Integrity and Provenance: 

Based on industry estimates, pharmaceutical companies incur an estimated annual loss of $200 billion due to counterfeit drugs globally. About 30% of drugs sold in developing countries are considered to be counterfeits. A blockchain-based system could ensure a chain-of-custody log, tracking each step of the supply chain at the individual drug/product level. Furthermore, add-on functionalities such as private keys and smart contracts could help build in proof of ownership of the drug source at any point in the supply chain and manage the contracts between different parties. For example, a company called iSolve LCC is currently working with multiple pharma/biopharma companies to implement its Advanced Digital Ledger Technology (ADLT) blockchain solutions to help manage drug supply chain integrity.

Pharma Clinical Trials and Population Health Research: 

It is estimated that 50% of clinical trials go unreported, and investigators often fail to share their study results (e.g. nearly 90% of trials on ClinicalTrials.gov lack results). This creates crucial safety issues for patients and knowledge gaps for healthcare stakeholders and health policymakers. Blockchain-enabled, time-stamped immutable records of clinical trials, protocols and results could potentially address the issues of outcome switching, data snooping and selective reporting, thereby reducing the incidence of fraud and error in clinical trial records. Further, blockchain-based systems could help drive unprecedented collaboration between participants and researchers around innovation in medical research in fields like precision medicine and population health management.

Cyber Security and Healthcare IoT: 

According to the Protenus Breach Barometer report, there were a total of 450 health data breaches in 2016, affecting over 27 million patients. About 43% of these breaches were insider-caused and 27% due to hacking and ransomware. With the current growth of connected health devices, it will be very challenging for existing Health IT infrastructure and architecture to support the evolving IoMT (Internet of Medical Things) ecosystems. By 2020, an estimated 20-30 billion healthcare IoT connected devices will be used globally. Blockchain-enabled solutions have the potential to bridge the gaps of device data interoperability while ensuring security, privacy and reliability around IoMT use cases. Companies such as Telstra (user biometrics and smart homes), IBM (cognitive Internet of Things) and Tierion (industrial medical device preventive maintenance) are actively working around these use cases.

If you would like more insights on blockchain in the healthcare industry #weshouldtalk

And The Unexpected Cost of Health

Avoiding The High-Cost of Healthcare

Many patients these days believe that if they have health insurance, most or all of their medical expenses will be covered by their health insurance plan. But, in today’s sophisticated health insurance plans, patients are finding out-of-pocket costs are really beginning to add up, whether it be a co-pay or a portion of a medical bill that is not covered by insurance.

Consumers should begin reviewing medical bills closely…extra or incorrect charges are becoming more commonplace. In fact, Consumer Reports noted that one-third of privately insured patients have received these types of bills. And 53 percent said the situation was not resolved to their satisfaction

Calling your doctor’s office to ask if he or she is covered under your insurance is not enough. A doctor might participate with your insurance for some things (products), but not others,” Additionally, some doctor/dentists may suggest that they “Participate” with your insurance company, but this does not always mean they are an “In-network” provider!

Never rely on physician/dentist website when checking whether a doctor is in or out of network. Websites are frequently out of date…some websites are better than others. There is no national standard of what each should look like.

In an effort to conserve time and save money, patients should feel free to pepper doctors with a list of questions before starting any treatment…“Is this procedure or test really necessary?” “What are the alternatives?” “Can we wait and see?” “Are there other ways to treat this?”

To really collaborate with your physician/dentist, you should state your preference and express your feelings. Don’t be intimidated by the white coat!

One out of three consumers has received a “surprise medical bill” from a doctor or dentist -- and it happens more frequently than you think. Unfortunately, the health care system isn’t so transparent as to who is or is not in your network!

One of the most common surprise medical bills that patients receive is from the emergency room. You may visit a hospital that you are told is in network, but the radiologist doesn’t participate with your insurance.

There are other examples; when having surgery, the anesthesiologist is often out of network and patients routinely receive a huge bill for their surgery. Being treated for sleep apnea? Majority of dentists treating the disease are not in-network with medical insurance companies and patients are often shocked when receiving a bill approaching $6-7,000! You have to be diligent.

This all happens to a lot of people, often under the worst circumstances!

Some states, such as New York and California, have protections in place against unexpected medical bills. But others states have yet to follow suit. There are numerous horror stories about huge medical bills after routine medical procedures where the costs were never disclosed to the (patient).

Some of this is a result of cumbersome diagnostic codes and confusing paperwork. Some doctors/dentists simply don’t know ahead of time whether a specific kind of blood test is covered under a certain diagnostic code. This often leads to rejection by the insurance company, AFTER the procedure, and a surprise bill for the patient.

There are so many more regulations to meet these days, and it’s often frustrating for doctors. They often spend a considerable amount of time on administrative work when they really want…need to care for patients.

It’s becoming a problem that is leaving people frustrated with the medical system. If you have questions (on a bill), call the insurance company or your provider to find out what went wrong. Know what your deductible and your co-pay is. Many people don’t know this. If you have co-insurance, know what portion you are responsible for.

If you call the physician or dentist, ask for the billing department and make sure to get a clear understanding of why you received the charge, ask for an estimate and any insurance requirements IN WRITING. Also, double check with the insurance company and see if the billing department’s answers line up.

If your medical or dental practice has experienced the patient with an unexpected bill #weshouldtalk

A Patient and an Employee Walk Into a Courtroom

Practice/Patient Privacy Policies Can Prevent Financial, Reputational Or Other Harm

Dental assistant, phlebotomist, hygienist, front office…any other practice employee is new on the job. They are excited and want to share their new position with their social media network. They snap a selfie or two to share the moment, then send it off to Facebook, Instagram, Twitter and Snapchat, with the click of a button, in just seconds. Problem?

Perhaps this is not a new employee. Maybe they’ve been with you quite a while, part of the “family”…through ups and downs – lately, mostly downs – had a challenging time at home last night, and are feeling a tad frustrated right about now. He/she picks up their smart phone, puts on their best “exasperated” face, snaps a selfie, and captions it with a summary of their frustrated state of mind, off it goes to the interweb. Not a problem, right!?

How about this… end of another great day at work. Back office had a great day of production, met a team goal, and bonus is on the horizon. “Let’s all huddle together for a group photo and sharing the love with a few thousand of our best friends online”!? More “likes”, “follows” on our Insta and Facebook page(s)! So much awesome!

Okay…pump the brakes!!

Now, let’s think about…HIPAA

On its own, a work selfie may amount to bad judgment and a violation of your company’s cell phone policy.

But, what if there happens to be protected health information in the background…a patient in the operatory? Is there a open nurse kiosk screen in the background? What about a patient’s name placard on a door? Or a rounding white board with patient status or surgery information? When your employees are excited or frustrated, are they more or less likely to notice these items as HIPAA hazards?

Privacy Concerns

HIPAA isn’t the only risk. Selfies that incorporate patients can violate privacy laws. Also, in nursing facilities, CMS considers photos or videos of residents that are demeaning or humiliating to be abuse. While it is less likely and more extreme for selfies to include abusive context (which typically require intentional conduct), it DOES happen, more than you might think!

In July 2016, a paramedic team was arrested and faced criminal charges after they engaged in a selfie “war” by text. They competed to take the most shocking pictures of themselves with patients in compromising positions. We’ve all seen this on You Tube, Facebook, etc.

Now…what you can do?

Confronting the force of social media can seem taunting, but providers have had great success with social media compliance culture campaigns.  Employees must understand that their phone might be their personal property, but HIPAA privacy laws and abuse laws apply when they use it at work.

Staff needs to be mindful of their surroundings and background if they are using their phones at work (and, of course, if this is permitted under your policies). Remind them that taking, with some very limited exceptions, a picture of a patient is never okay – even if the patient is in the background. This sounds obvious, but countless employees have made headlines by inadvertently making this mistake. Additionally, even taking a picture with the patient’s “Sure” as an approval can get you in hot water!! You MUST always…ALWAYS secure and retain a patient’s WRITTEN release to post ANY images with their likeness!

Educate employees and create a policy that informs your entire staff that inappropriate photos can violate privacy laws, constitute abuse, and lead to license discipline, criminal charges and lawsuits. Make sure they understand what’s at risk!

Finally, make the message pervasive. Not just at hire and once a year. ProPublica has posted 65 examples of inappropriate social media posts by nursing home staff since 2017. In many of the examples, the home had a social media policy. Social media use is rampant. Your social media compliance campaign should be, too!

If your medical/dental practice hasn’t created a social media/HIPAA compliance policy #weshouldtalk

Mitigating Stark Law and AKS Exposure

Protocol Development Can Prove Invaluable

Did you know that a dentist "renting" medical diagnostic sleep testing equipment then paying the entity who owns the equipment for patient testing constitutes fee splitting!? Or, paying for patient referrals can fall under both kick-back and Stark Law!?  

When making business arrangements between a medical or dental provider or an agency and another party, liability issues can get pretty janky, pretty quickly. Common-knowledge laws that affect most healthcare providers and their practices are Stark Law (physician self-referral) and the Federal Anti-Kickback Statutes (fee-splitting). Since both of these laws are Federal, they govern most situations wherein there is federal money involved as reimbursement, specifically, Medicare or Medicaid.

That said, 37 states, including California, have enacted their own particular laws that govern self-referrals and fee splitting. Many times the state law(s) may even be more strict than that of the Federal law, as is the case of California.

Since this is not intended to be a definitive guide on fee-splitting or kickbacks we will not discuss "safe harbors" that could protect the interests of providers. However, hopefully we can provide a broad-brush, quick overview of main California law(s) and some guidelines on how to avoid falling outside State regulatory guidelines.

California Fee-Splitting and Anti-Kickback Laws

Most notable is California Business & Professions Code Section 650 (B&P 650) and is the law that largely governs in the State of California fee-splitting and kickback practices for healthcare practitioners.

California B&P 650 reads as follows:

“(a) …the offer, delivery, receipt, or acceptance by any person licensed under this division or the Chiropractic Initiative Act of any rebate, refund, commission, preference, patronage dividend, discount, or other consideration, whether in the form of money or otherwise, as compensation or inducement for referring patients, clients, or customers to any person, irrespective of any membership, proprietary interest, or co-ownership in or with any person to whom these patients, clients, or customers are referred is unlawful.

(b) The payment or receipt of consideration for services other than the referral of patients which is based on a percentage of gross revenue or similar type of contractual arrangement shall not be unlawful if the consideration is commensurate with the value of the services furnished or with the fair rental value of any premises or equipment leased or provided by the recipient to the payer. “

This is California’s version of the Anti-Kickback statute, and is tougher than the Federal equivalents because not only does it cover reimbursements from Medicare and Medi-Cal (California’s Medicaid), but it also covers any reimbursements or transactions from private health insurance and Workers Compensation.

The next law to be aware of is California Health & Safety Code Section 445 (H&S 445) which covers medical referrals:

“No person, firm, partnership, association or corporation, or agent or employee thereof, shall for profit refer or recommend a person to a physician, hospital, health-related facility, or dispensary for any form of medical care or treatment of any ailment or physical condition.”

So, it’s pretty clear that California does not tolerate any referrals given or made from inducements of any kind.

The Corporate Practice of Medicine

There is a doctrine known as the Corporate Practice of Medicine, where non-physicians employ physicians specifically to practice medicine. The theoretical danger is that the corporation can put pressure on the physician to make decisions about patient care that are not in the best interests of the patient, but rather in the interest of making money for the corporation.

This concept is prohibited in California with California Corporations Code, Section 13408.5:

“No professional corporation may be formed so as to cause any violation of law, or any applicable rules and regulations, relating to fee splitting, kickbacks, or other similar practices by physicians and surgeons or psychologists, including, but not limited to, Section 650 or subdivision (e) of Section 2960 of the Business and Professions Code. A violation of any such provisions shall be grounds for the suspension or revocation of the certificate of registration of the professional corporation. The Commissioner of Corporations or the Director of the Department of Managed Health Care may refer any suspected violation of such provisions to the governmental agency regulating the profession in which the corporation is, or proposes to be engaged.”

Broad Guidelines to Remain In Bounds of the Law

While it may seem tricky to make a business arraignment as a healthcare provider, there are a few some simple guidelines that can keep you on the road to legal compliance and create a structure that can be justifiable to state regulator scrutiny.

1. Be certain that whatever fees for services that are negotiated and contracted in an agreement for services with a third party are:

Fair market value.

(1) This cannot be emphasized enough! You must seriously consider having in your contract a statement that says for x many injections, you get y $, or for x many hours, you get y $ per hour, or for x many months you get y $ pay and the dollar amounts are largely similar to the same fees of the area that the agency is geographically situated in.

Also, be certain that your contract clearly says that there is no control or undue influence over a physician when it comes to treatment of patients from another party. This includes proprietary interests by a physician into another agency or service they are referring patients to and vice-versa.

Conclusion

While the subjects of fair market value, inducements, Corporate Practice of Medicine, self-referrals, and fee-splitting are vast and can be discussed in volumes, this article was meant to be a very brief introduction to the laws of California fee-splitting and referrals. If you have questions about your arrangements, a smart and capable healthcare attorney should look over whatever contracts you make so that you don’t violate Federal or State laws and to ensure you are able to structure your contracts to fit within a "safe harbor" that protects your interests.

Other California Anti-Kickback and Fee-splitting Laws

California Business & Professions Code, Section 2273(a) states:

“Except as otherwise allowed by law, the employment of runners, cappers, steerers, or other persons to procure patients constitutes unprofessional conduct.”

California Health & Safety Section 445 (“Medical Referral Services”), states:

“No person, firm, partnership, association or corporation, or agent or employee thereof, shall for profit refer or recommend a person to a physician, hospital, health-related facility, or dispensary for any form of medical care or treatment of any ailment or physical condition.”

California Welfare and Institutions Code Section 14107.2:

Prohibits kickbacks in the context of public health services such as Medicaid and Medi-Cal.

In contrast, Section 14107.2 provides that the prohibitions in 14107.2(a) do not apply to:

“Any amount paid by an employer to an employee, who has a bona fide relationship with that employer, for employment with provision of covered items or services.”

If you need assistance minimizing your Stark Law or AKS exposure #weshouldtalk 

Bursting The Management Bubble

Intelligent Management Can Optimize Your Practice

Practice managers and administrators play an integral role in medical and dental practices. If provided with adequate resources, training, and educational opportunities, they can manage the business of care delivery — allowing their doctors and dentists to devote their time to patient care.

Here are 10 things every physician and dentist should know about these important individuals:

1. Practice managers and administrators wear many hats. They are experts in operations management, financial management, human resources management, organizational governance, risk and compliance management, and patient-centered care. Physicians can be confident that they are highly competent and efficient, and experts in medical/dental practice management. Employing a versatile and knowledgeable practice manager will position your organization for success.

2. Practice managers and administrators should pursue board certification in medical practice management. Board certification in practice management helps to validate that practice managers have the knowledge and skills to excel in a practice. Credentials in medical and dental practice management include CMPE, AADOM and FACMPE. If your managers do not have these credentials, provide them with opportunities and resources to pursue them.

3. Practice managers and administrators are playing an increasingly important role in serving patients. Managing a medical or dental practice involves cultivating a team of sophisticated and knowledgeable staff that ensures patients have a positive experience when they visit the office.

4. Practice managers and administrators can help guide collaborations with other healthcare stakeholders. There are many new ways providers and organizations are formally and informally collaborating and integrating. Practice managers can evaluate options, and strategically guide alignments that will benefit your practice. Physicians and dentists can be assured that practice managers have the tools and resources they need to understand and evaluate these opportunities, through education and networking that is facilitated by their professional memberships.  

5. Practice managers and administrators can help practices improve care quality while reducing costs. Managers can use EHRs to identify and group patients with chronic diseases and/or conditions, such as diabetes or periodontal disease. This can help practices better tailor their treatment approaches and target various patient populations. Providers should ensure that their managers have adequate training to use the software and tools available to them within their practices.

6. Practice managers and administrators navigate the complex regulatory environment. There are a plethora of federal regulations that practices need to be aware of and adhere to and practice managers can ensure groups remain in compliance and keep up-to-date with the evolving regulatory environment. Setting aside time for practice managers to learn about and understand applicable regulations will help to minimize your practice’s risk in the long run

7. Practice managers and administrators can implement and optimize technology that drives better patient outcomes and guarantees efficient practice operations. Managers can lead the charge in implementing EHRs and practice management systems, as well as other technology solutions that help patients, such as portals that are designed to engage patients in their care. Physicians/dentists and practice managers should collaborate to understand the technology needs of the organization, then to ensure that it’s operationalized thoughtfully. Additionally, be sure that staff are trained to input and access data accurately. 

8. Practice managers and administrators know their data. In addition to understanding and monitoring the many metrics that payers require, practice managers can use data to benchmark their organizations against their peers. They can use industry data to develop provider compensation plans, monitor the cost of running a medical/dental group, and assess how to best staff their practice. A benefit to setting aside time to participate in industry surveys is then accessing the survey data for free, which gives your practice up-to-date, relevant information.

9. Practice managers and administrators ensure patients have access to prompt, appropriate levels of care and manage cases between facilities.

10. Practice managers and administrators help providers devote their time to patient care. Because practice managers are experts in the business of care delivery, they can run an efficient practice, allowing physicians and dentists to devote 100 percent of their time to patients. In trusting and teaming with your practice staff, providers can spend their time visiting with and caring for patients, with assurance that practice operations are being run smoothly, efficiently, and effectively to position your practice for long-term success and sustainability.

Is your practice in capable hands? #weshouldtalk

More Than Just Splitting Hairs

Is Your Dental Office Paying For Patients?

In today's economic climate, costs are increasing, reimbursements are decreasing and although physicians and dental professionals are working harder, they're making less money.

In battling this inverse relationship, medical and dental professionals are seeking ways to enhance income. One temptation is referral arrangements, whereby a physician, dentist or lab/service provider is paid or pays another physician or dentist for patient referrals.

While this practice may be standard in other industries, it may be illegal "fee splitting" in the health care industry. Beware that such referral relationships may not be only a breach of ethical and professional standards, but also a violation of federal and state laws.

The American Medical Association and American Dental Association’s Code of Ethics provides that a "payment by or to a physician/dentist solely for the referral of a patient is fee splitting and is unethical." A physician/dentist is thought to engage in fee splitting when he or she divides a patient fee with a recommending physician/dentist. For example, a sleep physician and a dentist may have an arrangement whereby the dentist shares part of his or her fee by way of paying a “referral fee” with the sleep physician who referred the patient.

Similarly, the American College of Physicians Ethics Manual states, "a fee paid to one physician by another for the referral of a patient, historically known as fee splitting, is unethical."

The AMA's Code of Medical Ethics goes even further and mandates that "a physician may not accept payment of any kind, in any form, from any source ... for ... referring a patient to said source."

"Anti-referral laws" is a phrase commonly used to describe the collection of federal and state fraud and abuse laws that regulate physician referral arrangements. These laws not only invalidate referral agreements, but more importantly, may subject physicians and dentists to monetary fines, imprisonment, license revocation and other disciplinary actions.

Federal regulations

At the federal level, the anti-kickback statute and the Stark law heavily regulate physician referrals.

The anti-kickback statute explicitly states that it is a felony to solicit, receive, offer or pay anything of value, directly or indirectly, overtly or covertly, in cash or in kind, in return for referring patients or services for which payment is made by a federal health care program, such as Medicare or Medicaid.

The law punishes both sides of the deal, the referring and referred physicians. While the statute applies nominally to federal health care programs (thus patients or services not covered by these federal programs are outside the purview of the statute), the Stark law and/or state law may nevertheless prohibit the arrangement.

Under Stark, a physician may not refer Medicare or Medicaid patients for designated health services to an entity with which the referring physician (or his or her immediate family member) has a financial relationship, subject to some exceptions.

State prohibitions

At the state level, each state maintains its own position with regard to fee-splitting and physician referral agreements. Often, states create regulations that are enforced by the state's attorney general and which are applicable beyond just state funded programs/patients.

In Colorado, for example, a fee-splitting prohibition is contained in a subsection of the Colorado Medical Practice Act that subjects a physician to potential discipline for "dividing with anyone other than physicians with whom the licensee practices in a partnership, professional association, limited liability company, or medical or professional corporation any fee, commission, rebate or other form of compensation for any professional services not actually and personally rendered."

Steer away from the temptation

The key policy supporting the widespread prohibition of referral agreements and fee splitting is the notion that it creates a conflict of interest for the physician/dentist.

As the AMA's Code of Ethics states, a referral from a physician should be the product of the patient's needs and the referred physician's reputation, training and skill -- not the basis of an economic arrangement that could undermine patient trust.

Even the appearance of impropriety can compromise the patient's trust for both physicians/dentists involved and ultimately can undermine the public's confidence in the medical/dental profession. Currently, in Colorado, at least 12 dentists and a sleep physician are being investigated by the Dental Board, Medical Board, Attorney General and Office of Inspector General for a relationship that may constitute numerous state and federal regulatory violations.

When money is tight, human nature often allows otherwise prudent businessmen and women to make financial mistakes. Don't change your practice pattern to include suspect procedures simply to enhance short-term financial relief.

If you are unclear as to the legal ramifications of your exposure #weshouldtalk

Wild West Dental Sleep Medicine

Is Wild West Dental Sleep Medicine About To Be Wrangled In?

Is Wild West Dental Sleep Medicine about to be wrangled in?

In recent years, with all the dentists dipping their toes into the dental sleep arena, it seems there is becoming a shift in the idea of what exactly the dentist's role is, or should be. Should they test...should they diagnose, and on and on.

While it all seems so exciting, one fact that seems to be escaping us most is this...you're a DME! If, in all this excitement, you lose direction, here's a reminder!

While this may not sit well with some of you, in the world of dental sleep medicine, that's your role as a dentist! With all the recent pontification about residencies, exhaustive training, years of experience, she was previously owned by a little old lady in Pasadena...it all still boils down to one thing; your job as a dentist is to fabricate the appliance! And, why not? I mean, our dental clients love the idea that they are tasked with creating the appliance, billing insurance and allowing the medical doctor to assume the role of treating physician! Are you being restricted financially?? Well, Endeavor Health has a dental client in California who has CONSISTENTLY delivered over one-hundred appliances per month, for the past five plus years, at an average of $3,200 each!

We routinely see dentists promoting their voodoo medicine...supine CBCT to look at the airway, rhinometry to view the dimensional aspect of the airway. WOW!!! That all seems so fancy, "Stu"! But fact is, that's all useless data, for a few reasons!

First, if one wishes to needlessly expose the patient to the radiation of a CBCT to view the airway...well, that looks really great when the patient lays back on the dentist's shiny new $250k New Tom 5G Supine CBCT. BUT...that data is useless for this diagnosis!! And, when the dentist pulls out his/her acoustic rhinometer (Even in the hands of a qualified medical doctor, this is experimental when it comes to some medical health insurance companies, btw) and starts probing the patient..."WOW, that's high-tech equipment!!! But, again...useless data!!!

The challenge here...there is one factor, one essential factor that need be present whenever PROPERLY evaluating a patient for obstructive sleep apnea. Wait for it...THE PATIENT NEEDS TO BE ASLEEP! If you doubt or question that, here is the forth grade level math unpacking...do you or do you know someone who snores? Does that person snore when they are awake? There you go! The easy math equation to conclude that there is in fact a change in the dimensional aspect of the airway from a state of sleep and wakefulness! You are now a dental sleep expert!!!

But, wait...there's more!! Dental Sleep Medicine really is NOT rocket science! For all the pontification about "mini-residencies" (we just recently watched a long-time practicing sleep dentist stand-up and proclaim that two cases he saw were performed by dentists who were educated by a two-day dental sleep program when, in fact, those two cases were performed by his colleague, a 30+ year local sleep dentist...everybody's an expert!), the fantastic data, the numerous conferences, seminars, CE's, certificates on the wall, YEARS of experience and the knowledge of the multitude of comorbid issues and secondary diagnosis'...RLS, Polycythemia, Retinal Vein Occlusion, Drug Resistant Hypertension, et al...you can NOT identify, diagnose, treat, evaluate, prescribe, or even glove up!!! REMINDER

Dental Sleep Medicine is an evolving field! If you fail to evolve, you WILL become obsolete! And, there is a litany of programs designed to make you think this is the most difficult part of your practice. Fact is, it's not! It may, however,  absolutely be one of the most important, from a patient health perspective. And, we agree that, as a dentist, you should ABSOLUTELY be screening every patient who walks into your office!! When proper protocols are in place, our dental clients routinely discover things about their patients they never knew! Most common; 23-25% of their patient mix is either currently on PAP therapy or has been at one time and fallen off! But, be careful...it is a negligent dentist who suggests to a CPAP compliant patient that OAT is a better choice over the gold standard! And, for those of you who say, "My sleep physician doesn't have an 82% compliance amongst his CPAP patients...perhaps you need a new sleep doc?!

In any case, I digress! Point being, as a dentist, you are presented with groundbreaking opportunity here! For those patients shuffling thru life like The Walking Dead, on an aimless destination from point A to point B, you can be the awakening for them all (see what I did there?!)! Screen, educate and, for God's sake, get them to a physician and collaborate to provide the patient with the best treatment option(s) for their life and lifestyle! I promise the money will follow!

But, if it is your goal to pursue patients for the all-mighty dollar, to screen, test, "treat" and do it all in your office, the potential harmful ramifications WILL eventually catch up to you! And, it will likely be at the patient's expense!

For those of you who mope around with the "We live in Mayberry and there are no sleep physicians"; you are part of the problem! There are COUNTLESS IDTF organizations across the United States who will either personally deliver or drop-ship an FDA approved testing device to your patient's front door!!! And, the beauty, they will take care of the insurance verification and billing for the test, provide you a study read by a Board certified sleep physician all inside an average of five to eleven days! And, another YUGE bonus...again...wait for it...protect you from the disservice of placing your patient in financial harm's way when insurance discovers that the DME dispensed the testing equipment and the claim is denied!

Dental Sleep Medicine...there's a change a brewin'! Mount your steed! Yee Haw!

Quality vs. Value

Does "Quality" Help Patients?

Two quality metrics walk into a bar.

One demands, “Give me the best beer you’ve got!”

The other says, “Give me the second-best beer you’ve got.”

The bartender pours the beers and states, “You can have them both for free if you can tell me why this one is better than that one.”

Quality metrics were invented to quantify the ineffable, such as the taste of a fine lager or IPA. These days, we in Colorado are seeing local brews being listed in “International Bitterness Units” (IBU). Some may actually order their choice based upon this listing. At the very least, it gives us something to talk about while enjoying our beer.

Just as listing the IBU is new in beers, metrics did not always exist in medicine. The moment we became serious about quality is often cited as Dr. Philip Caper’s 1988 article “Defining Quality in Medical Care.” Even as medicine invented “quality” in the 1980s, Dr. Caper pointed to some misgivings about the terminology. His Health Affairs article suggests abandoning the word “quality” and rather using three terms that correlate to desirable medical outcomes: efficacy, appropriateness and the caring function. We know that certain interventions are efficacious in certain conditions; we can measure that. We know that certain interventions are appropriate and inappropriate in the sense of utilization; we can measure this. And we know that patients want “caring providers.” We likely cannot measure this very well, but it may be the most important of all the factors. The “quality” of care is more than all of these factors and perhaps quite different entirely.

Despite the prescient warning, we have not abandoned “quality, ” and its continued use has created an entire jargon: quality, measurement and value. Quality creates value. We are all preoccupied with creating value now. The term is rarely defined but often used: creating value to insurers, for payers, for health systems and even for patients. It appears to have a vague but unacknowledged relation to quality.

No one used to ask whether they got value when they went to the doctor’s office. We might have discussed whether we had a good doctor but never whether the experience was valuable. When we buy a car, we sometimes wonder whether we’re getting a good deal and whether the exchange had “value”. But when we sit with friends for a beer at the pub we never ask whether we’re getting a good value out of the experience. The use of value reflects an economic creep of the mission of medicine and a subtle deterioration of the relational aspect of “my doctor.”

Those things that are most important to us, and in some sense are valuable, we never ask if they “provide value.” Nor do we ask whether our evening at the pub was “quality time,” and rarely whether we just drank a “quality” beer. Remember “quality time” spent with our loved ones? Once we started asking this about the time with our children, it already represented an unacknowledged loss of the inherent relational component of life. Just so, once we started using “quality” and “value” in medicine, we had already lost its primary relational component. Although not stated in the original Health Affairs article, the discomfort with the term “quality” reflects a disquiet with conflating efficacy, appropriateness and caring with the much more subtle concept of quality.

Quality itself relates to the humanistic function of medicine, and not to its scientific trappings. As such, it is describable but not measurable. As an individual patient, whether our A1C is less than 9 percent correlates only tangentially with the quality of the care our physician provides. We might do better to have a lower A1C, but the factors involved in lowering our A1C, and how we perceive the care we have received, are not measured by the A1C itself. Presumably, the A1C captures the “efficacy” of the care received. It is a gross injustice to label this as “quality.” Substituting “quality” for “efficacy” defines patients as lifeless objects rather than by their characteristics as human beings.

Pay-for-performance takes medical quality metrics to the next level by using them economically. In our health care system, they are not working to improve care — why? Because the metric does not incentivize doctors to be more human. Instead, it rewards treating patients as commodities and lifeless objects. Doctors resent this incentive because commodification is dehumanizing. As incentives push doctors into becoming more mechanistic, we then invent new metrics such as “satisfaction surveys” to desperately attempt to pull them back towards a humanistic ideal. Satisfaction itself is now a commodity and subject to the rules of the market — massive, absurd inflation everywhere!

However, what does not work on an individual level, can work on a group or institutional level. Some payors, government and private insurance reimburse hospitals (more or less) depending on how they perform on various metrics. With some exceptions, this tactic appears to overall have improved medical care in America. Companies should be held responsible or rewarded for the quality of their products. Corporations have always responded well to financial incentives — it’s why capitalism works!

The fallacy in pay-for-performance resides in the jargon: quality, value and now “aligning incentives.” This innocuous phrase glosses over the distinction between corporations, which thrive because they transcend individual people, and doctors, who thrive because they are humans providing care to other humans. Be careful with your jargon, and be wary of individual metrics. 

If your practice is interested in providing patients with a more “value-based” experience #weshouldtalk

Are You a "Provider"?

Doctor...Dentist...

Integrating sleep medicine into the delivery of care for most dental practices has been a challenge for dentists as well as medical professionals, payors and patients across the board! When considering the litany of difficulties the dentist faces when introducing sleep medicine into his/her practice, our recommendation is always that a multidisciplinary care delivery model is the only true successful pathway for oral appliance therapy. 

Although sleep science has advanced significantly in the last decade, the delivery of care for breathing disorders continues to remain fragmented. For the most part, oral appliances have historically been underutilized. And, while there seems to be a natural tendency to create separate “shops” for each specialty, a multidisciplinary care stressing the need to be able to play in the same “sandbox” (care-under-one-roof model) offers distinct advantages to improved patient care, continuity of treatment, and the central coordination of benefits, both insurance-related and clinical.

Past Challenges to Integrated Care

Reasons for dental sleep medicine failing to integrate fully with the delivery of sleep medicine care are many. First, the growth of dental sleep therapy has not kept pace with the exponential growth of sleep medicine in the treatment of obstructive sleep apnea (OSA). Dentists who provide appliance therapy for breathing disorders are seemingly few in number. And, many of those who do often tend to step into the world of the treating physician, further creating discord when attempting to align with a medical practitioner. The most frequently reported occurrence is when the dentist usurps the position of the medical doctor and begins participating in the diagnosis of sleep disorders.

While the dentist is well-positioned to "screen" patients for sleep - based on their time looking directly into the airway - moving into the diagnostic process quickly takes the dentist outside of their scope of practice. We know that most all private third party medical insurance payors adopt Medicare guidelines, and most haven't understood or enforced their own guidelines...until now!

ENFORCEMENT IS FORTHCOMING

Presently, dental boards in Colorado, Iowa, Nebraska, Oklahoma, Georgia and North Carolina are currently looking to adopt specific Medicare guidelines within their respective Dental Practice Act(s)...expressly prohibiting the dentist "DME" from participating in the sleep study, even as much as having the testing equipment picked-up or delivered in their office.

Development of these guidelines is the result of the numerous "programs" that encourage the dentist to diagnose sleep patients and bill cash for this service -again, outside their scope of licensure. Another example of the dentist approaching "scope" concerns would be the dentist titrating the appliance, here the jury is still out. However, the general consensus in the medical community is; the dentist "adjusting" the appliance is akin to their stepping into the "treatment" of this medical diagnosis. In fact, Medicare has recently confirmed that their designating the dentist as the "DME" is to prevent them from attempting to assume a role of "provider". 

education is key

Another limiting factor in dental sleep medicine is the lack of education in the specialized use of oral appliance therapy for sleep disordered breathing among dentists and sleep physicians. 40% of dentists know little or nothing about oral appliances for treatment of OSA. Moreover, 49 responding dental schools of the 58 US schools recently surveyed reported only 3 hours of total curriculum time devoted to sleep medicine. With the exception of short courses offered by such organizations such as AADSM, dentists have relied on training from marketing/retail groups often associated with hoping to sell specific appliances and products for sleep medicine, charging exorbitant fees for equipment for which use, the dentist is unable to receive direct insurance reimbursement - if you can't get paid, it is likely outside your scope of practice!

ever evolving

To date, the knowledge of new materials, techniques, procedures, and continuing education has been limited to dental journals, periodicals, and advertisements. Efforts are under way to formalize dental sleep medicine training in our dental schools. The University of North Carolina School of Dentistry has already hosted conferences for dental educators across the United States and Canada in conjunction with developing predoctoral DDS and clinical residency programs.

collaboration rather than competition

Education to sleep physicians and technologists about oral appliances has been virtually nonexistent. Indeed, there have been recent efforts to train physicians to practice oral appliance therapy at professional meetings. Although this practice raises awareness of oral appliance therapy, it can undermine recognition of the training dental sleep experts undergo to properly evaluate the integrity of the teeth, the surrounding bone, and temporomandibular joints; to obtain accurate impressions and fit removable oral appliances (such as dentures and bite guards) to the teeth; and to minimize negative side effects of their presence.

Most importantly, communications between sleep physicians and dentists have been suboptimal in most healthcare settings. Even in academic settings, interactions between medical and dental professionals have been limited by their separate and different clinics, patient record systems, administrative priorities, and business models. There has been little need to co-treat patients in the past; thus the infrastructure and administrative support to encourage good communication between medical and dental sleep providers are lacking.

The co-treatment of patients with dental clinicians has been viewed as vaguely competitive to some physicians who provide CPAP as the primary treatment modality. This is directly correlated to the dentist assuming the role of provider, which more often than not limits referral of patients for oral appliance therapy. However, a truly successful relationship between physicians and dentists can only be established by close communication and sharing the common goal of patient centered treatment.

reimbursement driven therapy

Routine referrals to dentists is also often discouraged by the lack of, or limited reimbursement for, oral appliances by insurance carriers. Although Medicare recognized oral appliance therapy as early as 2005 as a potential first-line therapy for mild and moderate OSA and for patients with severe OSA who fail positive airway pressure therapy, many medical insurance carriers have only recently began to provide benefits for oral appliance therapy. Progress on this front has been slow and severely challenged by claims processing centers that are not prepared administratively to negotiate contracts with, or process claims from, dentists who are treating a medical condition, dental practices that are unfamiliar with submission of medical insurance claims and the appeal process upon denial, and reduced reimbursement rates for appliances that may not meet the dentist's costs for high quality oral appliances and the chair time required for comprehensive follow-up care.

follow-up is essential 

Post-intervention care with oral appliances also has left much to be desired. Patients undergoing sleep therapy are often reluctant to return to the referring physician for follow-up evaluation of the efficacy of oral appliance therapy, often citing the costs of another sleep study or its inconvenience as reasons for their reluctance. One study revealed, only 18% of patients receiving oral appliances underwent follow-up testing after the initiation of therapy. For those patients who do return for a follow-up sleep study and for whom there is residual sleep disordered breathing, another sleep study with yet further costs and inconvenience may be indicated after adjustment of the appliance.

evidence-based therapy

With the lack of these necessary follow-up tests, outcome measures are not been well documented for oral appliance therapy. While some controlled trials have shown improvement in daytime sleepiness and blood pressure on a short-term basis, the impact of oral appliances on cardiovascular disease on a longterm basis remains largely unknown. Such data on robust outcomes measures are needed to substantiate the long-term benefit of oral appliance therapy when compared to those of nightly use of positive airway pressure.

These outcome measures form the backbone of the proposed model's care of patients with obstructive sleep apnea. Outcome measures would serve as benchmarks for quality assurance and improve our understanding of the natural history of the disease with different interventions. Several outcome measures would be evaluated for quality assurance including compliance (patient-reported until reliable low-cost objective measures can be obtained), post intervention reductions in the AHI and excessive daytime sleepiness (e.g., Epworth Sleepiness Scale) and improvements in scales of neurocognitive functioning (e.g., psychomotor vigilance testing). Recently, mouth temperature-sensing compliance-monitoring chips embedded in oral appliances have been shown to be useful in recording hours per night and nights per week of therapy. This technology provides oral appliance data similar to compliance monitoring of positive airway pressure therapy. Long-term followup and monitoring of blood pressure, cardiac and cerebrovascular events, and mortality should be undertaken, so that the benefits of oral appliance and positive airway pressure therapies can be compared. A concomitant surveillance of adverse effects (both short-term and long-term) should be documented.

enter the provider

Safety and compliance monitoring should be conducted by a Board certified sleep physician every 4-6 weeks after an appliance is delivered until treatment efficacy and patient adherence have been established. The importance of this monitoring being performed by a physician is not only to ensure compliance, but only the physician can evaluate and address any patient adverse effects. Noncompliance (compliance being defined as ≥ 4 h use for ≥ 70% the nights) or failure due to intolerance of oral appliance therapy would trigger an alternative treatment strategy ordered only by the sleep physician. Some alternatives might include hybrid therapy, PAP therapy, or surgical intervention in select cases. A sleep specialist would manage any concomitant sleep disorders, which a patient may have to avoid overlap of visits. Cardiovascular and cognitive markers would be recorded for outcome data analysis and quality control.

In the end, there are specific Medical and Dental Licensing Laws and Practice Acts, which dictate the scope of practice for physicians and dentists  As per individual state law, laws only a licensed physician can make a diagnosis and treatment plan for sleep disordered breathing. Similarly, a dentist's scope of practice includes, and is limited to evaluating the candidacy of patients for oral appliance therapy as well as construction and fitting of the appliances. If the “care-under-one-roof model” is considered, comprehensive care can be performed within the practice parameters established by the CMS guidelines. Additionally, updated practice parameters are currently being prepared by the AASM for publication.

Responsibilities of sleep physician specialist:

  1. Assess patients with sleep related complaints.

  2. Order appropriate diagnostic tests and diagnose obstructive sleep apnea.

  3. Discuss treatment options with the patient based on practice parameters and standard of care guidelines.

  4. Counsel on behavioral therapy, sleep hygiene, weight loss, and driving precautions.

  5. Manage concomitant sleep disorders which often accompany OSA, such as restless legs syndrome (RLS)/periodic limb movement disorder (PLMD), circadian rhythm disorders, and insomnia.

  6. Follow and document comorbid conditions and impact of treatment on hypertension, diabetes, heart failure, arrhythmia, and neurocognitive function.

  7. Engage in active consultation with staff dental sleep expert on treatment plan.

  8. Participate in periodic multidisciplinary rounds and conferences.

  9. Provide follow-up sleep testing after OSA therapy has been instituted.

  10. Provide ongoing and routine follow-up patient care.

  11. Review compliance and manage potential complications or adverse effects of therapy.

Responsibilities of staff dental sleep expert:

  1. Evaluate patients for dental sleep medicine therapies.

  2. Discuss treatment options (mandibular advancement splints, combination MAS/PAP therapy, tongue retaining device, maxillofacial surgery, etc.).

  3. Manage coexistent dental disorders, such as bruxism.

  4. Counsel on dental hygiene and daily maintenance of oral appliances.

  5. Maintain communication with sleep physician specialist for outcome measures monitoring.

  6. Participate in periodic multidisciplinary rounds and conferences.

  7. Provide ongoing and routine patient followup care.

successful treatment is the only success

Integrating oral appliance therapy into the delivery of care for obstructive sleep apnea syndrome has been a challenge and few effective models exist so far. It is imperative that the sleep medicine community develops a realistic and effective model of this underutilized but promising treatment modality. The best structure is to integrate dental sleep medicine with the sleep disorders program is via a care-under-one-roof concept. Training, communication, education, marketing, and evaluating outcome data are vital. Such centers of excellence at academic institutions are best suited to lay this foundation. These institutional centers can provide care in their community as well as serve as a model of integrated care delivery for sleep medicine throughout the country in non-academically based sleep centers.

Thinking of integrating a successful dental sleep program into your practice #weshouldtalk

Sustaining Momentum During Sleep Integration

Five Behaviors Can Keep Bad Habits From Reasserting Themselves

In recent years, dental practitioners in North America have begun realize that status quo earnings have placed the financial health of their practice at risk. Office staff have become restive, and the principals are pushing to set a new growth trajectories. The introduction of sleep medicine presents a logical and determined way to embark on what often proves to be a Herculean and seemingly successful effort to create business within the practice. In the average dental sleep practice, earnings before interest, taxes, depreciation, and amortization (EBITDA) often increase by more than $600k annually, significantly improving cash position of the depressed dental office.

The story can be a salutary one for any practice failing to embrace proper introduction and integration of any new treatment modality. But thankfully, on the face it, and by the grace of the sheer force of will, a successful sleep medicine integration will unleash the hidden potential of most general dentistries and almost always sends financial performance into a measurable upward trajectory.

However, due to the recent creation of model upon model, many tough and painful decisions must be made before most dental practices’ pull the trigger. There are a litany of “sleep consultants” offering success models that are little more than illusion. Selling and promoting use of impressive looking, high-tech equipment and providing “cash-reimbursed” diagnostic scenarios often place the dental professional in harms way. As a result, going into 2017 dental sleep medicine finds itself under close scrutiny by state, federal and private, third party insurance regulators, and charging cash will no longer protect dentists from the guidelines they are currently working to circumvent with these practice models.

Aside from operating outside of regulatory guidelines, many “sleep consultants” fail to recognize the important functions of sustaining a successful sleep medicine program, which may sound obvious—and the actions required straightforward. But they’re not. “Consultants” routinely neglect regulations with their “ways to get around guidelines” because, understandably, they’re obsessed by their short-term gains. But, equally important to operating within regulations, and key to sustaining a successful sleep medicine program is to embed an “execution engine" - replicable processes that fundamentally change performance rhythms and decision making in the practice - raising sights beyond the strategic choices and daily initiatives to change how the sleep practice functions.

Building this engine requires five distinct behaviors:

1. Take independent perspective.

Challenge everything! It can be exhausting, but a practice that can sustain change will never be satisfied with the status quo. Continually looking for fresh facts rather than accepting the status quo and constantly guard against falling back on negotiated targets that staff may accept easily.

2. View the practice like an investor.

This is not always a mind-set that is popular inside the dental practice, and should not bejust for the management team. Passive employees kill the dynamism of a practice. Employees in a successful practice sustain their ownership by constantly challenging colleagues, not just getting along. They refuse to settle back into a leisurely pace of decision making. And they pursue new sources of value.

3. Ensure ownership down the line.

During the integration phase, there is an inevitable tendency for management and outside advisers to set the targets. We suggest this model be resisted. Practices’ with large front and back office teams that own centrally imposed initiatives, embedded in budgets without buy-in from managers, are most at risk of falling back into their old ways.

4. Execute relentlessly.

As with the incorrect bonus program, it’s all too easy for dental practices’ to allow the pace to let up once the initial improvement targets are achieved. After all, it’s simpler to delegate. But when the practice managers go back to high-level target setting and avoid immersing themselves in the details—perhaps on the dubious pretext that they don’t want to micromanage—the red flags should begin to raise.

5. Address underlying mind-sets.

Inspired employees make all the difference in a practice and in our experience conspicuously outperform those imprisoned by traditional command-and-control culture. Managers should not just challenge; they must instill meaning…recognize extra effort. And they should not assume that employees necessarily understand why the practice has to operate in a different way in the future.

Sleep practices’ that sustain integration continue to bring these five disciplines to their monthly operating meetings, to their annual budget discussions, and to their everyday management routines.

Sleep medicine success, they realize, ultimately is not about the scoreboard and whether the practice can deliver 20 or 20 appliances at the end of the month. It is whether the integration has ingrained a repeatable, replicable process that will drive better and better results long after integration is over.

Thinking about sleep medicine #weshouldtalk

Bonus Can Be a Bonus For Everyone!

It Pays to Pay!

Integrating the right team bonus program in any medical or dental office can be a major catalysts to the success or failure of the practice. As an example, with one of our practice management clients, Endeavor has played an active role in creating steady growth over a six year engagement - that’s production growth from $675,000 to $4 million…in six years! We’ve helped a number of practice start-ups that have gone from zero to $200,000 per month in less than five months. Others from zero to $160,000 per month in seven months! Never would any of these feats have been realized had it not been for team bonus programs.

Have you ever gone to the car wash and had your car cleaned or dried by the owner or manager rather than one of the employees? Perhaps they were busy or shorthanded and management had to pitch in?! Did you notice a higher level of service? Probably. The reason is because the manager/owner has a high level of vested interest in the business, and therefore your level of service was higher than from the non-owner employee.

The same can be said for your practice. The vested interest you have in your practice is much greater than that of your employees. But, what if you could increase your team’s level of vested interest and their feeling of “ownership” in your practice? What if your team became more like business partners than employees?

What if staff worked together as a team to ensure patients’ treatment can be worked into the schedule today instead of waiting until next week? What if time was spent explaining to a patient what might happen if they fail get that broken and decayed tooth fixed with a crown?

What if staff became excited as they showed patients the veneers on their own teeth and talked to about how great his or her new smile would look if they too got veneers? What if your financial coordinator figured out a way for the patients to afford their dental work with a combination of financing, insurance and treatment in stages?

Could this impact the amount of dentistry that patients decided to do in your office? What if you performed 50% more of the dentistry that you recommended? Wouldn’t that mean 50% more revenue on the same number of patients? How would that impact monthly income in your practice? Would this lower your stress level? What would this be worth to you?

A competitive bonus program will incentivize your staff and provide them a sense of ownership in your practice. The right bonus program might also even lower your stress because it brings a willingness of your staff to take on more responsibility. The right bonus program is a win/win for staff, the patient and can bring great benefit to your bottom line. The right bonus program will not cost you money, but will make you money! The right bonus program can change your practice, change your life and the lives of your staff.

On the other hand, the wrong bonus program can actually do harm to your practice and even be a disincentive for staff. Untold number of dentists have tried bonuses in the past that didn’t work for them. Staff rarely, if ever, made bonus – or if they did bonus, the bonus was so small that there was no incentive value. This is typically due to other issues limiting growth in the practice, which needs to be addressed before implementing the bonus program.

On the flip-side, over the years, Endeavor has had to “unravel” practice bonus programs that were developed by well-meaning dentists or “consultants”, but have actually ended up costing the doctor thousands…tens of thousands of dollars - staff was taking home a great bonus while the doctor’s income suffered.

Implementing a bonus in your office can be a bit of a dilemma. Your practice will have growth with a bonus, but the practice needs to be in a growth mode first before implementing a bonus. In other words, if the practice is not turning a profit then the bonus dollars will just come out of the doctor’s salary.

A bonus system is also not the end-all-be-all. Most medical/dental offices have several other issues that need to be cleaned up first before a bonus program is implemented. That is to say, a bonus program will not fix the wrong employee, or weak or non-existent systems, or poor case presentation techniques.

Upon engaging a new client, Endeavor typically begins working on several aspects of the practice…internal systems, organization, hiring the right people, efficiency, case presentation, phone techniques, etc., to set-up the practice revenue so there is now income available for the bonus to draw from. Once at peak level of performance, in combination with the bonus we very frequently see practice revenue increases in the 50-100+% range.

We also develop financial benchmarks that must met for a consecutive 90 days before implementing a bonus program - production at $25,000-$30,000 per doctor and hygiene treatment room per month. The practice should also be producing around $25,000 per employee per month.

A practice with four treatment rooms and four employees should be producing around $100,000 per month. We also want to see employee payroll expenses (bonus included) around 25-30% of collections. Payroll employee expense below 25% is typically an indication of a capacity blockage, and the resulting cost in lost production far exceeds the perceived savings.

There are a number of basics in the bonus program - many nuances and variables that cannot be covered in a blog post, so engaging the right consulting firm to help implement a bonus program so you get it started right and avoid some potential pitfalls. 

There are probably fifty bonus formulas in existence…collections…production…production minus write-offs plus collections and on and on…

Once the proper program is established, the bonus must be calculated and paid monthly. Anything beyond that makes staff wait too long - staff needs instant pudding! It is also important that everything is open and “above board.” Each staff member should know how the bonus was calculated each month and how much of the bonus each staff member received.

Things to consider…if staff gets the bonus too often then won’t they come to expect it?  Of course they will! If doing their job, they should come to expect it every month! If someone expects bonus without working hard, then you have the wrong person working for you!

The end all is that you receive after you give. You give first then you receive. So, when you distribute bonus, this should mean that your practice has received many times over - if bonus is 15% of profit, your practice profit margin is much higher than if bonus was not given. Lower stress, smoother running practice, happier staff, better patient care, growing practice, wealth, etc.

Want to double your revenue in 2017? #weshouldtalk

Four Plus Four Equals...Tired!

Sleep Deprivation May be Hiding in Plain Sight!

Have a toddler? Ask anyone you know who does or has had and they'll tell you that exhaustion doesn't always look how you'd expect. Obviously, sleepy little ones yawn and get cranky when they're tired like the rest of us, but let them get even a little more sleep deprived and they enter a state much feared by parents - overtiredness.

Often diagnosed as the ubiquitous “ADHD” when overtired, little kids will run around with manic energy, bouncing off the walls, and denying vehemently that they're tired. (Usually, to the point of a massive tantrum making it all too apparent they're actually exhausted to the point of near psychosis.) Kids sometimes even struggle to fall asleep when you finally wrestle them into bed because they're so amped up at that stage.

Turns out, many adults are actually similar. Sure, if you're up too late the night before, you'll feel all the classic signs of being under-rested (heavy eyes, yawning, etc.), but if sleep deprivation is cumulative, resulting from weeks or months of sound, restful sleep, your body will try to compensate.

In some cases, you'll begin to show signs that your sleep deprivation has entered a critical phase. If you see them, it's time to seriously consider revamping your sleep schedule.

1. YOU HAVE A PERPETUAL CASE OF THE MUNCHIES AND YOUR "GIRLY-FIGURE" IS BEGINNING TO SHOW IT!

If you can't keep your hands off the carbs and candy, it's time to have long think about whether you're really getting adequate shut-eye. Apparently, being inadequately rested can cause your body to produce more ghrelin, a hormone that makes you feel hungry and crave fatty and sugary foods in particular, and less leptin, the chemical that signals when you're full. If the brain doesn't get the energy it needs from sleep it will often try to get it from food.

2. YOU GET A JOLT OF ENERGY LATE IN THE EVENING

If it's approaching bedtime and you feel like you're flying, it's reasonable to think that your sleep deficit can't be that bad. But, that's exactly the wrong conclusion to draw from your night-time second wind. Your body is keeping you up for that last stretch of the evening so it can get you back into a rhythm. What frequently occurs is that after you’ve been running on empty you promise yourself you'll go to bed early. 'Early' rolls around and you feel fine, so you keep getting things done...but then end up with only 4 hours of sleep (again).

3. YOU'RE BEGINNING TO FEEL A LITTLE...BIPOLAR

The sun seems so bright and cheerful, the coffee tastes soooooo good and that cat going nuts with the empty cereal box is just hilarious. Is this a sign you're wildly happy with your life? Perhaps, but it could also be a signal that you've become too tired to control your emotions. The same could be said of feeling particularly dejected for no apparent reason. Ever find yourself tearing up over an embarrassing TV commercial? Sleep-deprived brains Are 60 percent more reactive to negative and disturbing images.

4. HAVE YOU SUDDENLY BECOME A KLUTZ?

Beyond just your emotions, when you're sleep deprived, it's your body too. We don't know exactly why, but sleepy people seem to have slower and less precise motor skills. In fact, miss enough sleep and you could end up effectively as uncoordinated as a drunk person. Going even for one night without sleep results in being about as impaired on early morning hand-eye coordination as someone who has a blood alcohol level of 0.10 percent.

5. YOUR SKIN IS BECOMING AFFECTED.

If you haven't had a break out this bad since you were a teenager, it's time to seriously consider whether your sleep schedule might be to blame. Your skin can also register your exhaustion simply by looking older. Poor sleep habits can begin making skin less firm and hydrated - in a word…older. Cortisol spikes in people who are stressed and sleep deprived can break down skin collagen, which stops it from being its usual smooth self.

6. LIBIDO...

Sleep deprivation can take a severe toll on your sex drive, and not just because, at some point, the only thing you want to do in your bed is sleep. For men, sleep deprivation can lower levels of testosterone, which also lowers their interest in being intimate with their partner.

7. WORK AND CREATIVE SUFFERS

Creativity demands a lot of cognitive resources and when you're sleep deprived you simply don't have that much mental horsepower to spare. You might start resorting to tired cliches and regurgitated presentations to keep up your end of conversations and responsibilities.

8. TROUBLE SHAKING A COLD

If you keep coming down with the sniffles - or can't seem to kick that never-ending cold - you may want to assess your sleep schedule. People who sleep fewer than seven hours each night have almost three times the risk of catching a cold than people who slept for at least eight.

While sleeping, your immune system produces proteins knowns as cytokine, that help protect against infections and inflammation. A few nights of poor sleep could lower your body's defenses against pesky viruses.

Do any of these worrying signs apply to your patients? #weshouldtalk

Is Healthcare Delivery Finally Back-to-the-Future?

The Telemedicine Revolution is Here

Year after year of big promises, telemedicine is finally living up to its potential!!

Being driven by faster internet connections, ubiquitous smartphones and ever-changing insurance standards, more health and dental providers are turning to electronic communications to do their jobs—and it’s upending the delivery of the health care system.

Doctor and dentists are linking up with patients by phone, email and webcam. They’re also consulting with each other electronically—often making split-second decisions on heart attacks and strokes. Meanwhile, patients are using devices to relay their blood pressure, heart rate and other vital signs to doctors so that they can manage chronic conditions at home.

Telemedicine also allows for better care in those rural locations where medical expertise is hard to come by.

At least ten times each and every day, Doctors Without Borders relays questions about tough cases from its physicians in Niger, South Sudan and elsewhere within its network of over 280 experts around the world, and back again via the internet.

In the many rural communities across the country, shifts of doctors and nurses work around the clock in “virtual care centers”… “hospital without beds” providing remote support for intensive-care units, emergency rooms and other programs in smaller hospitals from North Carolina to Oklahoma. Many of them without a 24/7 on-site physician.

Critical-care doctors sit at oversize video monitors, continually collecting data on far-flung ICU patients and watching for signs of imminent trouble. If a patient needs attention, physicians can zoom in via two-way camera—close enough to read the tiny print on an IV bag.

In the past eighteen months, ICUs monitored by specialists have seen a 35% decrease in patients’ average length of stay and 30% fewer deaths than anticipated. That translates to 1,000 people who were expected to die who got to go home instead.

As a measure of how rapidly telemedicine is spreading, consider: More than 15 million Americans received some kind of medical care remotely last year, according to the American Telemedicine Association, a trade group, which expects those numbers to grow by 30% this year.

This is not to say that telemedicine has found its way into all corners of medicine. A recent survey of 500 tech-savvy consumers had found that 39% hadn’t heard of telemedicine, and of those who haven’t used it, 42% said they preferred in-person doctor visits. In a poll of 1,500 family physicians, only 15% had used it in their practices—but 90% said they would provided they were appropriately reimbursed.

What’s more, for all the rapid growth, significant questions and challenges remain. Rules defining and regulating telemedicine differ widely from state to state and are constantly evolving. Physicians groups are issuing different guidelines about what care they consider appropriate to deliver in what forum.

Some critics also question whether the quality of care is keeping up with the rapid expansion of telemedicine. There’s also the question of what services physicians should be paid for: Insurance coverage varies from plan to plan, larger federal plans cover only a narrow range of services.

Telemedicine’s future depends on how—and whether—regulators, providers, payers and patients can address these challenges:

Are patients trading quality for convenience?

The fastest-growing services in telemedicine connect consumers with clinicians they’ve never met for one-time phone, video or email visits—on-demand, 24/7. In the case of a dentist treating obstructive sleep apnea and looking to meet requirements of a “face-to-face” physician visit, telemedicine eliminates the need for the patient to make a trip to the physicians office and, from a cost perspective, the telemedicine consult costs around $45, compared with approximately $100 at a doctor’s office.

Many health plans and employers have rushed to offer the services and promote them as a convenient way for plan members to get medical care without leaving home or work. Nearly three-quarters of large employers will offer virtual doctor visits as a benefit to employees in 2017, up from 48% this year.

Web platforms such as Teladoc, Doctor on Demand and American Well are expected to host some 1.2 million such virtual doctor visits this year, up 20% from last year, according to the American Telemedicine Association.

But, there is always the concern that such services may be sacrificing quality for convenience. Consulting a random doctor patients will never meet, they say, further fragments the health-care system, and even minor issues such as upper respiratory infections can’t be thoroughly evaluated by a doctor who can’t listen to your heart, culture your throat or feel your swollen glands.

In the May 2016 JAMA Dermatology, researchers posing as patients with skin problems sought help from 16 telemedicine sites—with unsettling results. In 62 encounters, fewer than one-third disclosed clinicians’ credential or let patients choose; only 32% discussed potential side effects of prescribed medications. Several sites misdiagnosed serious conditions, largely because they failed to ask basic follow-up questions.

The American Telemedicine Association and other organizations have started accreditation programs to identify top-quality telemedicine sites; the association also tells consumers to be wary of sites that sell products.

The American Medical Association has already began approving new ethical guidelines for telemedicine, calling for participating doctors to recognize the limitations of such services and ensuring that they have sufficient information to make clinical recommendations.

Who pays for the services

While employers and health plans have been eager to cover virtual urgent-care visits, insurers have been far less willing to pay for telemedicine when doctors use phone, email or video to consult with existing patients about continuing issues.

Thus far, 32 states have passed “parity” laws requiring private insurers to reimburse doctors for services delivered remotely if the same service would be covered in person, though not necessarily at the same rate or frequency. Medicare lags further behind. The federal health plan for the elderly covers a small number of telemedicine services—only for beneficiaries in rural areas and only when the services are received in a hospital, doctor’s office or clinic.

Bills to expand Medicare coverage of telemedicine have bipartisan support in Congress. Opponents worry that such expansion would be costly for taxpayers, but proponents say it would save money in the long run—as much as $2 billion over 10 years.

Doctor-to-doctor consultations are also seldom covered by insurers. Health systems such as Mercy, the Mayo Clinic and the Cleveland Clinic that provide oversight and expertise on strokes, intensive-care units and other specialty care to networks of smaller hospitals typically charge those facilities a monthly fee, which generally cannot be charged to patients.

These arrangements enable small hospitals to provide top-flight care to patients on-scene and to suggest that they partner with world-class health-care systems. And it’s less expensive than hiring their own specialists…a win-win…win!!!!

With the 2016 election behind us, the future of ACA is uncertain and the likelihood of HMO becoming more prevalent, hospitals are likely to invest in telemedicine systems to move away from fee-for-service payments and prepare for managed-care-type contracts that give them a set fee to provide care for patients and allow them to keep any savings they achieve.

Is the state-by-state regulatory system outdated?

Historically, regulation of medicine has been left to individual states. But, more and more, the 50 states set of fees, licensing fees and even definitions of “medical practice” makes less sense in the era of telemedicine and is hampering its growth.

Currently, doctors must have a valid license in the state where the patient is located to provide medical care, which means virtual-visit companies can match users only with locally licensed clinicians. It also presents administrative hassles for world-class medical centers that attract patients from across the country.

At the Mayo Clinic, doctors who treat out-of-state patients regularly follow-up with them via phone, email or web chats when they return home, but they can only discuss the conditions they treated in person. If the patient wants to talk about a new problem, the doctor has to be licensed in that state to discuss it. If not, the patient should talk to his primary-care physician about it.

To date, 21 states have joined a compact that will allow a doctor licensed in one member state to quickly obtain a license in another. While this move is welcoming to some, some telemedicine proponents would prefer states to automatically honor one another’s licenses, as they do with drivers’ licenses.

But states aren’t likely to surrender control of medical practice any time in the near future, and most are considering new regulations. So far, in 2016, more than 200 telemedicine-related bills have been introduced in 42 states, many regarding what services Medicaid will cover and whether payers should reimburse for remote patient monitoring as well as store-and-forward technologies (where patients and doctors send records, images and notes at different times) in addition to real-time phone or video interactions.

What counts as practicing medicine?

The exploding volume of health information on the internet is raising new questions about what constitutes the practice of medicine. Some web-based businesses enable consumers to consult doctors overseas, who don’t have U.S. medical licenses, but post fine-print disclaimers that they are providing information and not medical advice.

Are such services “practicing medicine” without a license? The exact definition varies from state to state, and state medical boards generally don’t investigate unless a patient files a formal complaint. Even then, boards have jurisdiction only over individual doctors licensed in their state, not companies, or physicians overseas.

How will this change competition?

Telemedicine is shaking up traditional relationships between providers and payers and fueling the rise of medical “megabrands” whose experts are increasingly competing for patients in each other’s backyards.

Insurers such as Anthem and UnitedHealth Group are offering their own direct-to-consumer virtual doctor-visit services, rather than simply paying for plan members to use those from web-based vendors. Major health systems are making their physicians available for virtual follow-ups and chronic-disease management, as well as urgent-care visits, to new and existing patients.

Endeavor Health is working with our medical doctor clients to create a “Clinic in the Cloud” that would allow rural and incapacitated patients across the country to access physicians without going to an actual office . This will open up a world of relationships across a spectrum of health-care providers that we haven’t seen to date!

 

If your practice or health organization sees telemedicine in your future #weshouldtalk

Bridging Gap in Medicine Practice and Healthcare Business

Physicians Now Make-up Over 40% of Mid-career Business School Enrollment

Revenue Cycle Management, Incentive Compensation, and Workflow Analysis. These are words that are rarely, if ever heard in medical school but are critical to a physician’s ability to operate their office. Pay for Performance, Profiling, and Payment Methodologies. Other words that physicians are faced with every day but not taught in medical school or residency programs. In our 21st century, you need to be not only a physician but also a businessperson to succeed in today’s healthcare environment. While many physicians play golf on their day off, significant number these days are reviewing accounts receivable. Having an interest in business make it easy to navigate the changes in medicine that are ever-changing, but just as importantly, it is necessary if you hope to operate a successful practice.

Traditional IPAs, PHOs, and Networks have now been replaced by ACOs, Medicare Advantage Plans, EBM (Evidence Based Medicine), and P4P (Pay for performance). There is much more to the practice of medicine than the knowledge learned in medical school and residency. How does a doctor bridge the gap? Every doctor has the capacity to learn how to manage their business and those that do will financially do better than those who do not. What ancillary services can you provide that will enhance your practice revenue? What are my competitors (yes they are in competition with you for market share) doing that I am not. Why do other physicians in my specialty seem to be making more than me? These are the questions that need to be asked on a quarterly basis so that you are not left behind. Although time is a limiting factor, giving up a day off every now and then to make sure your practice is working well is a fair trade. Your office manager, practice management consultants, accountants, attorneys, and others can make recommendations, but in the end the physician has to take ownership for implementation. If this is not the way you want to practice, the alternative is to become an employee of a hospital, large medical group, or other organization and only have to worry about seeing patients. 

In adversity, there is always opportunity. This sentence allowed many entrepreneurial physicians to create successful medical management companies and is going to allow a new generation of entrepreneurs to flourish as health care reform takes hold. As a physician, I have traveled between the business world and the medical world seamlessly. When a physician talks to lay people in business about health care they listen. It is critical for the physician to leverage that in their discussions with managed care organizations, hospitals, etc.

The economics of healthcare has always been that the total expense for any service is equal to the sum of the price for the service multiplied by the quantity of services. In a fee for service world, this is borne out in Florida because as the unit price for a service was reduced the number of services increased. Hence, Florida’s utilization is one of the highest in the country. In a capitated world where the total expense for services is fixed, the quantity of services is reduced leading to a higher price per service but in some instances, underutilization.

 

It is critical for all physicians to understand that with their signature, they control almost 100% of all health care expenditures while at the same time they only receive 18% of all funds spent. With the advent of ACA, the world as we know it has changed. What is quality care and how do you get there? Is cost effective care the equivalent of quality care? How do I compare to like physicians with similar patients as it relates to utilization of resources and outcomes? For individual physicians or groups to be successful, they will have to prove that they can deliver a better product than their competitor. This is the next phase in the evolution of medicine. The bridge between practicing medicine and running a business is getting shorter. How we take advantage of the opportunity will determine our viability in the future.

What's the health of your medical practice? #weshouldtalk