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The HuTech Chronicle Q4-2005 (click here to subscribe)
You can count on HuTech for relevant and up-to-date information surrounding the evolving and complex healthcare environment. The HuTech Chronicle is sent out quarterly to subscribers and archived in this section. Your E-Mail address is all we need. We will bring you reliable information along with opinions, when appropriate, on the best ways to use the information.

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From Our Readers
Can we ban cell phone use in our office?

Regarding staff:
Yes. Cell phones should not be allowed to be turned on in the workplace. Aside from the interruption to the employee who answers the call and the co-workers and patients who then listen to the conversation, current cell phone technology offers a variety of issues related to privacy. Although unfortunate that it must be a concern, a valid fear is the potential violation picture phones represent to the workplace. Your cell phone policy should be clear to staff and reassure them that emergency calls may always be received on the office line.

Regarding patients:
Partly. It is difficult to ban cell phone use entirely in the waiting room. Placing signs that “request” cell phones be turned off is an option but some practices do not like the appearance the signs have in the waiting room. It is easier, however, to firmly request patients turn off cell phones when entering the examination rooms. Often, practices simply use the rationale that cell phones in the clinical area may potentially interfere with equipment. This is a position with which most patients will have no problems complying, allowing your clinical staff and patients to have an uninterrupted encounter.

Practice Management
Employee Motivation
It is easy to recognize how a high level of staff motivation results in an efficient office, satisfied customers and employees who are excited about coming to work. The difficult aspect is determining what will motivate staff. Monetary incentives are certainly one way to attract staff, but money is not always a motivational tool. In fact, bonuses and monetary rewards can actually decrease staff motivation if an equitable structure is not in place or the distribution system begins to show inconsistencies. Often bonus systems ultimately result in an expected reward rather than an earned reward. Studies have shown that if a bonus is expected and either not received or received but not to the anticipated level, employee motivation and satisfaction can significantly decrease. The expectancy theory evidences a fatal flaw in mismanaged or poorly designed bonus systems.

According to this theory, employees must have three different types of beliefs: 1.) expectancy – a belief that their effort will affect performance; 2.) instrumentality – a belief that their performance will be rewarded; and, 3.) valence – a perceived value of the expected reward. If any of these three beliefs is not met, the employee’s motivation will decrease accordingly. For example, if staff believes that regardless of their effort, they are doomed to fail, there is no reason to put forth the extra effort (expectancy). Likewise, if staff believes that they can achieve a goal with extra effort, but have no faith that achieving the goal will be noticed or rewarded, there is no external motivation to put forth that effort (instrumentality). Finally, if an employee does not perceive the end reward as having any value (valence), there is again little external motivation to work extra to achieve the desired goals customer satisfaction, office efficiency, job fulfillment. Unfortunately, as an employer, there is no way to know what reward upon which employees place value. For that reason, some employees are moving to cafeteria-style bonus systems or benefit plans that offer a variety of options from which employees can choose. Others are simply asking.

In certain cases, employers are allowing employees to provide input in their benefit plans, job descriptions or bonus structures. Simple techniques to improve job satisfaction and employee motivation include job enlargement or job enrichment. Enlargement includes giving employees more tasks to perform at the same level (a horizontal move). Enrichment includes giving employees more responsibilities or moving to a position requiring higher level skills (a vertical move). Each of these methods provides a tool that certain employees will embrace, increasing their motivation and performance. This may not apply to all employees, however. Other motivational options include offering creative healthcare benefit packages, health spending accounts or non-monetary benefits such as flexible hours. An August 2005 Harris Poll survey showed that 35% of adult workers state that maintaining their current benefit level is more important than receiving a pay increase (a 6% increase from 2003). Also, 61% stated that if faced with the choice; receiving no pay increase but maintaining their current health insurance benefit would be the preferred alternative.

For this reason, employers must look to more than just salary as a means to keep and motivate their staff. Certainly, employees are often initially attracted to a position using salary as a primary or significant consideration. Long term satisfaction, job performance, and overall happiness may be less influenced by dollars, however, and employers must act accordingly.

Clinical Services
E-Prescription Regulations
Earlier this year the Department for Health and Human Services (HHS) announced proposed regulations for standards to support electronic prescription services. The regulations are proposed to adopt standards for:

• Transactions between prescribers and dispensers for new prescriptions, prescription refill requests and responses for prescription refills, changes or cancellations, and related messaging and administrative transactions.
• Eligibility and benefits inquiries and responses between drug prescribers and prescription drug plans.
• Formulary and benefit coverage information, including information on the availability of lower cost, therapeutically appropriate alternative drugs, when appropriate or applicable.

The plan is for these regulations to be in place January 1, 2006 at the time the Medicare Prescription Drug benefits begin. The regulations call for networks using a combination of security services related to the transmission of electronic prescriptions, including:

• Credentialing upon enrollment of prescribers and dispensers in a valueadded network (i.e., access authorization).
• A minimum of a user ID (i.e., access control) and password (i.e., authentication) for access to eprescribing software.
• Use of a network-assigned electronic signature process (i.e., integrity and audit control).
• Transmission of the prescription message through a private leased line or through the Internet using a virtual private network (VPN) connection or the Secure Socket Layer (SSL) protocol (i.e., transmission security).

Electronic signature standards are also part of the regulations and will use the network to verify authenticity and authorization of users. Although the regulations are still in the recommendation phase, their initial submission was 7 months prior to the date mandated by the Medicare Modernization Act (MMA). The National Committee on Vital and Health Statistics has been called upon to help develop recommendations for the e-prescription regulations and updates can be found at http://ncvhs.hhs.gov/.

For additional information regarding these standards visit the Department of Health and Human Services at http://www.hhs.gov/.

Financial Management
Staffing and Turnover
Staffing and staff turnover are concerns in any industry. We have previously addressed the importance of properly training staff as a means to improve job satisfaction, increase job performance and reduce turnover. According to a 2003 MGMA report, the median turnover percentage for reception and medical record staff in group practices was 14.39%. Nursing and clinical support staff ran a 9.61% turnover rate while billing and data entry staff had a median of 8.27%. Looking at the responsibilities placed on staff in today’s medical practice and the constant changes in managed care plans and policies, these numbers are perhaps not entirely surprising. Yet, these percentages can be easily reduced by providing a few tools to help your staff meet the demands of the medical practice.

Consider your reception staff. An outside study determined the average primary care office receives 50 phone calls per physician per day. In an eight-hour work day, that equates to one telephone call every 9.6 minutes. With the assumption that each call takes approximately 4-7 minutes to answer the phone, identify and address the caller’s question or issue and complete any necessary follow up, that leaves potentially 2 minutes for your reception staff to resume their daily tasks until the next call comes in. Of course, calls are not received in a neat 9.6-minute pattern which results in hold-times, messages or “to-do” lists that require follow-up later in the day. Tied to this most routine reception task, electronic messaging and an EMR make a strong case as tools to help your staff improve their efficiency and productivity. Rather than take a message, search for and pull a paper chart, make a return phone call and then address a patient’s question, the EMR allows the receptionist to immediately view the chart and address or forward the question to the appropriate staff member. Electronic messaging allows the reception staff to attach the patient’s electronic medical record, provides an electronic record of the original request and permits tracking of requests to ensure each is addressed – eliminating the possibility of losing that small piece of pink paper which is the only copy of the patient’s question. Online access is further discussed under Business Development, but the implications to this example are simple in that available online interaction between staff and patients reduces phone call volume and the number of interruptions for non-emergent, routine inquiries.

The mere presence of tools designed to increase office efficiency and reduce turnover are only as effective, however, as the staff trained to utilize them. The “paperless” advantages that the EMR and Internet provide may quickly become sources of frustration and confusion if staff is not comfortable or properly trained on their functionality. Training is often an area that is compromised due to its high cost – both time and money. Using technology such as WebEx or Glance, online training videos or a “train-thetrainer” method are techniques to reduce the sticker shock. These options may also provide you and your staff flexibility when scheduling the sessions, allowing self-directed training rather than the more rigid commitment of a conference call or on-site session. And certainly there are more options than just these few. The important element is to be certain that the technology and tools provided to your office are used appropriately and to their full potential. At that point you have the best opportunity to promote staff efficiency and longevity.

Special Topic of Interest:
Keep your eye on Deere
The Chicago Tribune recently reported an interesting development at the John Deere Company. For a number of years, Deere has been running a “for profit” healthcare division. Begun as a way to manage healthcare costs, Deere hired a few doctors and contracted with others to provide medical services to its employees. (Deere currently has about 46,000 employees, worldwide.) At the time, the strategy looked like a move back to the “company doc”. It seems they were pretty smart.

The Tribune article reports that United Healthcare has agreed to purchase the 500,000-member organization for $500 Million ($1,000 per member). The article goes on to explain that “the recent trend suggests that with regard to healthcare organizations, bigger is better”. “The larger organizations are better able to negotiate with hospitals and doctors and to make better use of efficiency enhancing technology.” I think we know what that means.

As for John Deere, they were proactive about addressing a problem. We can’t be sure they accomplished everything they intended, but the company did get $500 Million. Not a bad reward.

Business Development
Online Patient Interaction
Medical office websites and interactive solutions offer tremendous potential for communication between practices and patients. Providers and administrators harbor many valid fears, however, when considering access to or dissemination of healthcare information over the Internet. Proper implementation, management and security can put these fears to rest and allow the practice to experience the benefits of online patient interactions.

The concerns over online interactions are always valid and with patient safety and security first and foremost. These concerns, however, should not prevent a practice from moving forward with website development and online solutions. Appropriate recognition of your patient population, patient expectations and security needs are all important aspects to creating an online service that will best represent your practice and be a functional tool for your patients. Security and privacy requirements are important considerations, but not prohibitive barriers. Other important considerations include the providers’ and staff ’s expectations and willingness to participate in the online interactions. It is paramount that the providers and staff develop a procedure to receive, respond to and address each correspondence or request received via their website. This requires a commitment on behalf of the staff, but their commitment will be rewarded in many other aspects of their current job duties.

One obvious advantage to staff is the potential decrease of incoming telephone calls. Website functionality such as preregistration, appointment requests and prescription refill requests all permit patients to submit information to the practice without requiring a telephone call that may disrupt staff workflow. These requests can then be handled at the staff ’s convenience (within a reasonable timeframe as specified in a practice policy). Pre-registration also allows staff to verify insurance eligibility prior to patient arrival, reducing the possibility of claims submitted to expired or incorrect insurance carriers. Online appointment requests have shown to decrease last-minute cancellations and noshows which ultimately improve practice revenue. Online prescription refill requests decrease administrative and clinical staff requirements by prompting patients to complete required fields and ensuring that the necessary information is received. These requests can also be linked to an electronic health record making patient history, medication interactions, and other clinical information needed to properly address the refill request easily accessible. Additionally, pharmacy information entered by the patient is readily available to the staff and approved requests can be faxed or emailed directly to the pharmacy with the only phone call being to advise the patient the prescription is ready.

Website implementation and utilization offer many additional efficiencies, but a commitment from staff and providers are required. Policies on response time to patient requests must be clearly visible on the website and must be consistently adhered to by staff. Patients must also be made aware of requests that are appropriate for online submission versus more urgent needs that require a telephone call. As your patient population becomes more comfortable and familiar with your website policies, both patients and staff will soon recognize the benefits that online patient interactions can bring. Perhaps initially somewhat intimidating, a well-maintained practice website can quickly result in improved patient satisfaction and economic and operational gains.

Managed Care
2004 Census Statistics

Overview

• The percentage of the nation’s population without health insurance coverage remained unchanged, at 15.7 percent in 2004.
• The percentage of people covered by employment-based health insurance declined from 60.4 percent in 2003 to 59.8 percent in 2004.
• The percentage of people covered by government health insurance programs rose in 2004, from 26.6 percent to 27.2 percent, driven by increases in the percentage of people with Medicaid coverage, from 12.4 percent in 2003 to 12.9 percent in 2004.
• The proportion and number of uninsured children did not change in 2004, remaining at 11.2 percent or 8.3 million.

Race and Hispanic Origin (Race data refer to those reporting a single race only.)

• The uninsured rate in 2004 was 11.3 percent for non-Hispanic whites and 19.7 percent for blacks, both unchanged from 2003. The uninsured rate for Asians declined from 18.8 percent to 16.8 percent.
• The uninsured rate for Hispanics, who may be of any race, was 32.7 percent in 2004 — unchanged from 2003.
• Based on a three-year average (2002-2004), 29.0 percent of people who reported American Indian and Alaska native as their race were without coverage, higher than the rate for native Hawaiians and other Pacific islanders (21.8 percent) and for those of other race groups, but lower than that of Hispanics. Comparisons of twoyear moving averages (2002-2003 and 2003-2004) showed that the uninsured rates for American Indians and Alaska natives and for native Hawaiians and other Pacific islanders did not change.

Nativity

• While the proportion of the foreign-born population without health insurance in 2004 (33.7 percent) was unchanged from 2003, the rate for the native-born population increased (from 13.0 percent in 2003 to 13.3 percent in 2004).

Regions

• The Midwest had the lowest uninsured rate in 2004 (at 11.9 percent), followed by the Northeast (13.2 percent), the West (17.4 percent) and the South (18.3 percent).

The 2004 census, and additional statistics are available at:
http://www.census.gov/Press-Release/www/releases/archives/income_wealth/005647.html

Note from the Owners
With regard to healthcare issues, expectations for 2006 are high. And that is ONLY in part because things certainly can’t get much worse.

This is the year that HuTech will introduce “integration”. We will begin to show the power small practices can have simply by working more closely in an integrated environment. The primary tool we have developed and that is now available is the electronic medical record (EMR) delivered through application service provider technology (ASP). Our practice management solution for scheduling, billing/collection and reporting is currently delivered using this same technology. The central server concept will enable the doctor’s office to make efficient use of the EMR without the need to expend valuable resources dealing with the hardware, the software, the technology and the continuing development of an extremely powerful tool. Those who are proactive and take advantage of the opportunity will be entering into a collaborative venture with other physicians. The collaboration may prove to be the most valuable aspect of the entire venture.

We will be looking for opportunities to talk with each of you about not only the new initiative, but the opportunities that exist to begin to align the small practices, to do more to help ourselves and to relieve the pressure of the managed care burden.

The best to you all in 2006!

"There is nothing you can do about your early life now, except to understand it. You can, however, do everything about the rest of your life." -Warren Bennis

DISCLAIMER: The subject matter and commentary contained in The HuTech Chronicle is meant to be strictly informational. The content is intended to be educational and informative and not construed as specific advice for any individual practice. Implementing policies and procedures into a practice may require discretion on the part of the reader.

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