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1 SPECIAL ISSUE! Acos Quality Healthcare with Quantified Savings EHRs: Are you getting paid? icd-10-cm is Still coming, Are you Ready? do you Know your online Reputation? April chicago medical Society THE medical SociETy of cook county

2 I am ISMIE. Loyal. Partners. Service Driven. Cesar J. Herrera, MD, Cardiologist Advocate Medical Group - Heart and Vascular of Illinois When I learned that a health care system wanted to purchase my practice, I was concerned about my medical liability insurance coverage. Then I found out I could keep my ISMIE Mutual insurance... that made the decision easier. It made me think there are probably a lot of ISMIE policyholders who don t know they can keep their ISMIE Mutual coverage through the flexible options for employed physicians. I m now an ISMIE policyholder and an Advocate Medical Group associate. Great partners for me, great partners for my practice the perfect combination. If you re considering integrating your practice with a hospital, remember you can remain an ISMIE policyholder with the same coverage. You can still depend on ISMIE s loyalty to your practice, exceptional service to every policyholder, solid coverage with flexibility and innovative risk management! Depend on ISMIE for your medical liability protection so you can focus on the reason you became a physician: to provide the best patient care possible. Not an ISMIE Mutual policyholder and interested in obtaining a comparison quote for your medical liability coverage? Contact our Underwriting Division at , ext. 3350, or us at Visit our web site at ISMIE Mutual Insurance Company Protecting the practice of medicine in Illinois P

3 editorial & art Executive Director Theodore D. Kanellakes art director Thomas Co-Editor/Editorial Elizabeth C. Sidney Co-Editor/Production Scott Warner contributors Bruce Japsen; Abel Kho MD, MS; Nelly Leon-Chisen, RHIA; Howard Wolinsky Chicago Medical Society Officers of the Society President Thomas M. Anderson, MD President-elect Howard Axe, MD Secretary Kenneth G. Busch, MD Treasurer Philip B. Dray, MD Chairman of the Council Robert W. Panton, MD Vice-chairman of the Council Kathy M. Tynus, MD Immediate Past President David A. Loiterman, MD Chicago Medicine 515 N. Dearborn St. Chicago IL Chicago Medicine (ISSN ) is published monthly for $20 per year for members; $30 per year for nonmembers, by the Chicago Medical Society, 515 N. Dearborn St. Chicago, Ill Periodicals postage paid at Chicago, Ill. and additional mailing offices. Postmaster: Send address changes to Chicago Medicine, 515 N. Dearborn St., Chicago, IL Telephone: Copyright 2012, Chicago Medicine. All rights reserved. FEATURES 12 ACOs Why form an ACO? Here are reasons you can bank on. By Bruce Japsen 15 Social Practice Social media means more than virtual socializing. You can use it in your practice, too. By Howard Wolinsky 18 The Ratings Game Do you know what your online reputation is? by Howard Wolinsky practice management 6 Meaningful EHRS By Abel Kho, MD, MS 8 County Board President Highlights Changing Culture Toni Preckwinkle makes tough decisions to build infrastructure for tomorrow. By Scott Warner 10 ICD-10-CM is Still Coming By Nelly Leon-Chisen, RHIA Association 20 Have a Say in Policy, Legislation Committees are the backbone of CMS and are open to all members. 21 CMS Advocates for Payment Reform Your leaders express SGR concerns to congressional reps. By Elizabeth Sidney 22 Welcome to Our New Members We re now more than 1500 voices stronger. 30 Reaching Out to Specialists CMS president meets with Chicago urologists. By Scott Warner 34 Calendar of Events 12 Volume 115 Issue 4 April 2012 April

4 message from the president A New Beginning Thomas M. Anderson, MD, is a radiologist at Mercy Hospital. He is the 163rd President of the Chicago Medical Society. Welcome to the newly redesigned and reconceived Chicago Medicine magazine. This issue marks the first redesign of our venerable magazine in more than 20 years, and is another reflection of our commitment to better serve you and keep up with the changing times. The new Chicago Medicine will arrive at your home each month, giving you the opportunity to review it at your leisure. Beyond the sleek modern appearance, you ll find articles of greater range and depth. Each issue will help you to adapt in a shifting and uncertain healthcare environment. Thanks to our partnership with the American Bar Association s Health Law Section, you ll receive timely legal, legislative, and regulatory updates. Through columns, articles, and opinion pieces the magazine will address new technology, social media, advocacy initiatives, clinical and academic issues, public health, and medical education. Another focus will be the financial and economic trends affecting our profession, and helping you make your practices more efficient and prosperous. Our experts are well versed in contracting, risk management, practice sales and mergers. A rejuvenated Chicago Medicine goes hand-in-hand with our redesigned CMS website. With new electronic capabilities, we are expanding the CMS physician community with online forums, committee sections, and blogs. In addition to a job board and career center, CMS now offers DocBookMD, a smartphone platform and HIPAA-compliant professional network for doctors to communicate, collaborate, and coordinate. At members urging, we re also building a coding exchange that will keep all specialties informed of coding updates and provide meaningful communication with medical billing experts. Students and residents, women physicians and senior members can access sections built around specific needs and interests. The Chicago Medical Society was founded to raise the standards of medical practice and promote public health in the community. In keeping with that core mission, CMS launched its first publication in 1891, a periodical designed to inform and educate members. In 1902, CMS began publishing a weekly bulletin that eventually evolved into a newsletter and magazine. Now, as the magazine enters a new era, we welcome your feedback and suggestions for continued improvement. Thomas M. Anderson, MD President, Chicago Medical Society 2 Chicago Medicine April 201 2

5 Dr. Masucci found a better way. The power of a web-based network like athenahealth is that it has created a seamless integration between our billing and clinical services, allowing us to focus on patient care, which is our ultimate goal. Here s what he did. After 30 years running a solo pediatric practice, Dr. Peter E. Masucci* found a better way to manage his practice. Now, he spends more time with patients than ever and he s getting paid the money he s owed when he s owed it. With athenahealth s integrated webbased billing, practice management, and electronic health record services, he s been able to: Reduce Days in Accounts Receivable by 65%** Increase the percentage of claims paid at their contracted rate from 62% to 99%** Find that elusive work/life balance he s been searching for Here s how he did it. Low-cost, web-based, CCHITcertified software A constantly updated, patented database of insurance and clinical rules Back-office services to handle your most time-consuming tasks To learn more about our billing, practice management and EHR services, visit l or call * Dr. Peter E. Masucci participates in athenahealth s National Showcase Client Program. For more information on this program, please visit ** Actual results may vary. ah_chicago_med.indd 1 3/13/12 4:37 PM

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8 PRACTICE MANAGEMENT meaningful EHRs maximizing incentives and minimizing penalties by Abel Kho MD, MS " for the medicaid program a qualifying physician can earn up to $63,750" By now, you have probably heard a lot about the federal incentive program to encourage EHR adoption and Meaningful Use (MU) of EHR systems. The incentive programs run through the Centers for Medicare and Medicaid Services (CMS) and are designed to help all practicing physicians adopt a certified EHR system and use their EHR system in an effective manner, exchange electronic health information, and help health care providers examine and review and improve their quality of care. The incentives from both programs are significant: for the Medicare program, a qualifying physician can earn up to $44,000, and for the Medicaid program a qualifying physician can earn up to $63,750. CMS has developed a tool to help you determine your eligibility for the incentive programs at 15_Eligibility.asp. Here s what you need to know to maximize your incentives and minimize penalties for both programs: Ehr incentive Program timelines April 18, 2011 Medicare MU Attestation Begins September 5, 2011 Illinois Medicaid Registration Begins February 29, 2012 Last Day to Attest to MU for 2011 november 17, 2011 AIU Attestation Begins February 28, 2013 Last Day to Attest to MU and Receive full Incentive march 31, 2012 Last Day to AIU Attest for Payment Reductions Start for Non- Meaningful Users december 31, 2016 End of Medicare MU Program medicare incentive program medicaid incentive program February 28, 2017 Last Day to Attest to AIU and Receive full Incentive december 31, 2021 End of Medicaid MU Program AnyonE participating in either program has the option of switching to the other program once. There are no fee schedule penalties for the Medicaid program, but providers who see Medicare patients will be penalized starting in 2015 if they have not achieved Meaningful Use of an EHR, regardless of which program they participate in. Despite the challenges of adoption, the Medicare and Medicaid EHR Incentive Programs represent an unprecedented opportunity to support the transition to safer, high-quality health care. The HIT Regional Extension Center program was established through the Office of the National Coordinator to provide assistance to health care providers working to achieve Meaningful Use. for more information and assistance, please contact the Chicago HIT REC at if you practice in the 606xx zip codes in Chicago; otherwise, contact the Illinois HIT REC at medicare Administered by federal CMS You are eligible for the full incentive payment if you have billed Medicare at least $24,000 during the past year. You need to register at the Federal CMS incentive site before you can attest at EHRIncentivePrograms/20_Registrationand Attestation.asp. The program runs from 2011 to 2016 and incentive payments are paid out over five years. To receive the maximum incentive payment, you must demonstrate 90 days of Meaningful Use starting in The deadline to attest to Meaningful Use for 2011 was February 29, You can attest to Meaningful Use before you have accrued $24,000 in Medicare billing. Your incentive payment will not be paid out until your maximum billing has been accrued or the calendar year ends, whichever comes first. Penalties will begin in 2015 in the form of fee schedule reductions for providers who have not become Meaningful Users of a certified EHR. Incentives for physicians practicing in Health Professional Shortage Areas will be increased by 10% for those physicians who accrue the maximum allowable charges. medicaid Administered by Illinois DHFS You are eligible for the full incentive payment if 30% or more of your patient volume is Medicaid. If you are a pediatrician, you are eligible if 20% or more of your patient volume is Medicaid, but your incentive payment will be reduced if your volume is less than 30%. You need to register before you can attest. Registration is a two-step process that starts with the federal CMS site. Get started by following the road map at Illinois DHFS at ehr/path.html. For the first participation year, physicians need only to demonstrate that they will adopt, implement, or upgrade (AIU) to a certified EHR system. The program runs from 2011 until 2021 and incentive payments are paid out over five years, though qualifying physicians may take a year off without penalty, as long as they start by To receive the maximum incentive payment you must attest to AIU by 2016 and demonstrate 90 days of Meaningful Use in The state of Illinois opened up attestation to AIU in November 2011 with a deadline of March 31, There are no fee schedule reductions or penalties for those who do not achieve Meaningful Use. 6 Chicago Medicine April 201 2

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10 County Board President Highlights Changing Culture Leadership makes tough decisions to build infrastructure for tomorrow by Scott Warner "We have to make sure our system operates effectively and efficiently enough to support 100,000 newly insured patients." Addressing the Chicago Medical Society (CMS) Council on Feb. 21, County Board President Toni Preckwinkle says she believes there is hope down the road for the Cook County Health and Hospitals System (CCHHS) if all healthcare sectors collaborate with one another. She highlighted CMS role in County governance as one such example. As a member of the nominating committee that selects candidates for the governing Independent Board, CMS makes recommendations whenever a vacancy opens up on the Board. Preckwinkle said she is now partnering with that Independent Board, and CEO Dr. Ram Raju, to lay a new foundation for public health delivery, investing in the services that uphold County s mandate and mission. A new foundation is the only way, Preckwinkle said, to push the boundaries on what had for too long been the status quo. In 2014, the Affordable Care Act will dramatically expand the number of insured people, giving the 100,000 existing County patients a new lifeline. The legislation incentivizes providers to keep people healthy and away from expensive services. Preckwinkle called health reform a good thing because public health providers will finally receive compensation for the care they deliver. However, she says, the legislation challenges the CCHHS to be more competitive. We have to make sure our system operates effectively and efficiently enough to support 100,000 newly insured patients. Because, the question we will soon face is this: if individuals have the choice will County Board President Preckwinkle with Joy Cunningham, Illinois Appellate Court Justice; and CMS Past Presidents Drs. Sandra Olson and Robert Vanecko. they continue to choose County? Preckwinkle asked. Or will we become a system for those who fall through the social safety net and the undocumented for whom we get no reimbursement? Last year alone, the CCHHS provided more than $500 million of uncompensated care to a patient population that has a high percentage of individuals with complex, serious illnesses, she said. Preckwinkle says the Independent Board assembled Vision 2015, a comprehensive plan to eliminate waste, lower costs and improve services. Every decision made by the Board, Dr. Raju, and Preckwinkle is shaped by four basic principles: fiscal responsibility, innovative leadership, transparency and accountability, and improved services. In just nine months, the Board passed two budgets, solving a roughly $800 million gap. The Board also cut 50% from the president s office, and Preckwinkle reported that she took a 10% pay cut. Legislators in Springfield are considering a proposal that could significantly impact the health system, she said. The state of Illinois formally sent a request to the federal government seeking a Section 1115 Medicaid Waiver for the CCHHS effective July The waiver would allow current patients of CCHHS to enroll in a Cook County Medicaid network with absolutely no cost to the state if their income is less than 133% of the federal poverty level. As Preckwinkle explained, This would mean that more than 100,000 patients currently in the CCHHS system could gain coverage before And it s important to emphasize they are patients who are already being treated by our system without compensation. Emphasizing that the health care system s problems are also the County s problems, the Board President said that while she stands firmly by the independent provision of health care, if there are administrative areas budget and finance, human resources, where we can be of assistance, then we will assist. Preckwinkle stressed that care cannot be sorted into categories public health, private, and charity. There are no simple answers for improving the public health system. Progress will depend on effective collaboration across many sectors, she said. On a final note, Preckwinkle said that she came before the Council to emphasize that County is serious about engaging health care stakeholders to work together, so efforts can move forward. I want to hear from you! she concluded. Following her presentation, several physicians in the audience asked how they could volunteer their services. 8 Chicago Medicine April 201 2

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12 practice management ICD-10-CM is Still Coming! Why should you care, and will you be ready? by Nelly Leon-Chisen, RHIA The Department of Health and Human Services (HHS) announcement in February that it will delay the ICD- 10 compliance deadline of Oct. 1, 2013, shook the healthcare IT world and left many providers wondering what this all meant. Although a new date has not yet been set, it is clear that HHS still sees value in ICD-10 implementation and that the preparations should NOT stop. This article will answer many of the questions you have and provide tips on organizing your implementation efforts. What is it? Diagnosis codes are embedded in nearly every clinical and billing operation nationwide. And while physician payment per se may not be driven by diagnosis coding, the codes justify the services provided and demonstrate medical necessity. ICD-10-CM is an upgrade and expansion of the current diagnosis coding system. The new coding sets include laterality (i.e., left, right or bilateral), combination codes, and identify the chronology of encounters for injuries (e.g., initial, subsequent or sequelae). Although the code set is huge, physician practices will use only a small subset. Non-specific codes still exist for use when the medical record documentation does not support a more specific code. A companion procedure coding system Feature ICD-9-CM ICD-10-CM Minimum number of digits/characters Maximum number of digits/characters Number of codes 13,000 ~69,000 Supplemental classification Laterality (right vs. left) Alphanumeric vs. numeric Excludes notes Placeholder characters V codes and E codes No Numeric, except for V codes and E codes Yes No No, incorporated into classification Yes Alphanumeric with all codes starting with an alpha character and some codes with alpha 7th character extension Exclude 1 and Exclude 2 Yes X Decimal point Yes Yes (ICD-10-PCS) will only affect hospitals reporting inpatient services. Physicians will continue to use CPT and HCPCS for their professional services. Why is it important? ICD-10-CM implementation is a high-risk activity. Failure to carefully plan and coordinate can create coding and billing backlogs, cash flow delays, increase claims rejections/denials, bring about unintended shifts in payment, and place payer contracts and/or market share arrangements at risk due to poor quality ratings or high costs. Inaccuracy in clinical coding creates distorted or misinterpreted information about patient care, which can also result in faulty investment decisions to improve health delivery. Worst case scenario? Your payments will stop. Why should we change? ICD-9-CM is more than 30 years old and in spite of annual revisions, it cannot keep up with changes in medical knowledge or the demands for detailed administrative data needed to evaluate quality of care, value-based purchasing, and to support biosurveillance and public health initiatives. The final Health Insurance Portability and Accountability Act (HIPAA) rule adopting ICD-10 as a standard was published in January 2009 and set a compliance date of October 1, 2013 a delay of two years from the compliance date initially specified in the 2008 proposed rule. Development ICD-10-CM is the clinical modification of the International Classification of Diseases created by the World Health Organization. The clinical modification for use in the U.S. was developed in consultation with physician groups, clinical coders, and other users of ICD-9-CM. Examples of the organizations involved include the American Diabetes Association, American Psychiatric Association, American Academy of Pediatrics, American Academy of Neurology, and the American Academy of Orthopedic Surgeons, to name a few. Anticipated benefits ICD-10-CM incorporates much greater clinical detail and specificity than ICD-9-CM. Terminology and disease classifications have been updated so they are consistent with current clinical practice. The modern classification system will provide much better data needed for: Measuring the quality, safety, and efficacy of care. Reducing the need for attachments to explain the patient s condition. 10 Chicago Medicine April 201 2

13 PRACTICE MANAGEMENT Designing payment systems and processing claims for reimbursement. Conducting research, epidemiological studies, and clinical trials. Setting health policy. Operational and strategic planning. Designing health care delivery systems. Monitoring resource utilization. Improving clinical, financial, and administrative performance. Preventing and detecting health care fraud and abuse. Tracking public health and risks. major differences and similarities ICD-10-CM shares many similarities with ICD- 9-CM, especially in the classification format and conventions. The code structure has changed slightly to accommodate code expansion and improvements to the classification. The table on the left shows the major differences. ICD-10-CM has retained several conventions already familiar to users of ICD-9-CM, such as instructional notes, abbreviations, cross-reference notes, punctuation marks, and relational terms. One of the more significant changes for ICD-10-CM is the clarification of exclusion notes. ICD-9-CM provides a single type of exclusion note, whereas ICD-10-CM has two types of excludes notes each has a different use; but both indicate that codes excluded are independent of each other. ICD-10-CM includes the following improvements and major modifications: Significant improvements in coding primary care encounters, external causes of injury, mental disorders, neoplasms, and preventive health. Advances in medicine and medical technology since the last revision. Codes that detail socioeconomic data, family relationships, ambulatory care conditions, problems related to lifestyle, and the results of screening tests. More space to accommodate future expansions (alphanumeric structure). New categories for post-procedural disorders. The addition of laterality specifying which organ or part of the body is involved when the location could be on the right, the left, or bilateral. Expanded distinctions for ambulatory and managed care encounters. Expansion of diabetes and injury codes. Creation of combination diagnosis/symptom codes to reduce the number of codes needed to fully describe a condition. Greater specificity in code assignment. 1 Centers for Medicare & Medicaid Services, Quick Reference Information: ICD-10-CM Classification Enhancements. January Inclusion of trimester information in pregnancy codes. preparation Many professional societies and coding organizations have already started developing tools and resources to expedite the transition. Along with specialty-specific tools, they are developing maps to crosswalk codes and data for analysis, while also preparing to train members and staff. Yes, change is difficult and requires hard work. However, as Secretary Sebelius was quoted in the HHS press release, ICD-10 codes are important to many positive improvements in our health care system and worth the effort. Ms. Chisen is Director of Coding and Classification, American Hospital Association. Preparation checklist Organizing the effort Emphasize a team approach Identify a physician champion for the practice Enlist help from the practice manager, coding, and billing staff Establish a communication plan and ensure that everyone is aware and kept up-to-date on progress. Early planning will make the transition smoother and less overwhelming. Planning and impact analysis Examine every application where diagnosis codes are captured, stored, analyzed or reported Assess impact to electronic health record Contact system vendors and determine conversion plans and specifically whether your current systems will be supported Estimate budget based on whether new billing and collecting systems will be required or whether cost of upgrades are included in current maintenance Consider training budget for coding staff and develop training plan Develop detailed project plan Analyze business processes and determine whether workflow changes are required Develop to-do list of tasks, timeliness and assign responsibility Evaluate plans for introduction of new technology and determine impact on coding Implementation Assess level of preparedness of business associates and vendors Determine software vendor timeliness for software upgrades Assess quality of medical record documentation Complete tasks identified during planning process Deploy codes and software changes Conduct training of coding staff Convert any superbills or other forms where coding is captured Conduct internal and external testing (clearinghouses and payers) Post implementation and on-going evaluation Evaluate software upgrades Review quality of coded data Conduct additional staff training Reinforce physician documentation training Assess impact on reimbursement April

14 acos Quality Healthcare with Quantified Savings By Bruce Japsen 12 Chicago Medicine April THouGH an overwhelming number of physicians across the country are unsure about whether to form let alone participate in an accountable care organization for Medicare patients, Chicago physicians Lee Sacks, MD, and Scott Sarran, MD, are more than a year into a private sector effort designed to achieve the same thing. Dr. Sacks, the top doctor at the Chicago area s largest provider of medical care, and Dr. Sarran, the senior physician at the state s largest insurance company, are leading Advocate Health Care and Blue Cross and Blue Shield of Illinois into what they think will be a national model in shared savings between provider and insurer. ACOs work toward a common goal of pushing less expensive and higher quality medical care by reducing or eliminating unnecessary medical services by more effectively managing the care. An ACO is designed to have physicians and hospitals take responsibility for managing the care of a patient. The reward for a successful outcome is the provider being awarded with extra reimbursement from money saved by the improved quality. We need to bend the cost curve, said Dr. Sarran, vice president and chief medical officer at Blue Cross and Blue Shield of Illinois, which provides health benefits for more than seven million people in Illinois. Current cost trends are unsustainable. The private sector effort between Advocate and Illinois Blue Cross was launched in January 2011 with more than 400,000 patients. Advocate expects to build on its experience this year when it applies this spring to form an ACO under the Medicare Shared Savings Program, which is a voluntary program formed under the landmark Affordable Care Act signed into law two years ago by President Obama. The current fee-for-service system creates a lot of bizarre incentives, said Dr. Sacks, vice president and chief medical officer at Advocate Health Care, which operates a dozen hospitals in Illinois and has more than 250 sites of care. Hospitals get paid for keeping people in the hospital as opposed to keeping people healthy. Though ACOs can vary widely in the private sector, the Medicare model involves doctors having to achieve about 30 quality measures. The Advocate-Blue Cross model also has quality and outcome measures. Advocate will work to reduce the length of patient hospital stays and for the need to readmit patients who have already received treatment but later have been found to

15 AccountAble care have had a complication or infection that warranted a return to the hospital within 30 days. To achieve their goals, Advocate last summer hired nearly 60 outpatient care managers, who are largely nurses, with some social workers, who help physicians by monitoring their patients and making sure they adhere to their treatment plans. For a patient with chronic disease like congestive heart failure, you need to make sure the patient or their significant other really understands the condition, Dr. Sacks said. A doctor spends five minutes with a patient and (the patient) forgets what they need to do even before they leave the office. The care manager first meets with the patient in the doctor s office and then follows up with a phone call or even a home visit as the patient s first point person for everything from a medication refill to home care instructions or someone who can fast-track an appointment in an Advocate doctor s office, Dr. Sacks said. The case manager nurses are there to assist physicians in areas like follow-up, ensuring patients return when necessary or are following the doctor s orders or taking their medications. Care managers also do the intangibles like connecting them to a community agency or church support group, Dr. Sacks said. By more aggressively managing the medical care and adding staff to make that happen, Advocate is hoping to reduce the need for patients to get sicker and end up in the hospital where medical care tends to be more costly. Illinois Blue Cross Dr. Sarran, the insurance company s vice president and chief medical officer, said physicians and hospitals in the ACO will be paid for outcomes rather than being paid for procedures and visits to the doctor s office. Some of the things Illinois Blue Cross measures include patients satisfaction and quality measures such as whether patients are getting breast cancer screenings and whether Advocate hospitals and health facilities are reducing their infection rates. Advocate has also initiated pilot projects to reduce re-admissions. If successful, Advocate will figure the savings and quality improvement in future ACO agreements with other payers, Advocate said. Doctors do not get an upfront payment to help fund their ACO with Advocate. Rather, a bonus waits if they achieve certain outcomes. There is no upfront payment, Dr. Sarran said. If there are savings by Advocate providers against a control group and if Advocate hits a set of quality, safety and service measures built around continuous improvement, they are then eligible to share in the savings. They have to create the savings and hit the quality, service and safety measures. In January 2012, the Centers for Medicare and Medicaid Services began accepting applications from providers to begin forming ACOs. Advocate said it expects to have an application in this year. Hospitals get paid for keeping people in the hospital as opposed to keeping people healthy. April

16 accountable care Physicians will be paid based on patient outcomes and will share in any losses insurers sustain due to poor patient outcomes. We applaud CMS for offering flexible and creative options to help Advocate and other provider organizations better serve our patients and communities, Dr. Sacks said. We are excited about the opportunity to partner with CMS to form an ACO. It s just a matter of determining the best model for Advocate given our size and other business considerations. Physicians across the country are concerned about the potential high expense of forming an ACO that will contract with Medicare. And there is reason to think that way. Advocate spent about $10 million in 2011 on care managers, data systems and infrastructure. Unlike smaller doctor practices, and as the state s largest medical care provider with more than $3 billion in cash on its balance sheet, Advocate has the access to capital to more easily invest in an ACO, according to the September Moody s Investors Services report. A doctor practice on a smaller scale is going to struggle, Dr. Sacks said. But a small doctor practice of 10 or more physicians could get it done by either working through an independent practice association that has more resources or by investing in management resources and technology. You could do it on a smaller scale, but you have to be in an organized system of care, Dr. Sacks said. The Medicare shared savings program will have significant start-up costs, said Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association, which represents more than 20,000 physician practices. Challenges remain with this program. But after doctor groups complained last year and high profile practices such as the Mayo Clinic and Intermountain Health Care balked through their trade group, the American Medical Group Association, that they were unlikely to participate in the Medicare ACO effort, the Obama administration issued new rules through the Centers for Medicare and Medicaid Services to ease physician concerns. CMS said participating doctors will get access to $170 million in the first year of savings to the Medicare program. Doctors will be able to use that money toward building their ACOs. CMS also reduced by half, the number of quality measures doctors will have to comply with but a CMS spokesman said it will still be more than 30 quality benchmarks. CMS move late last year made ACOs more palatable to doctors. Coupled with massive start-up costs and the initial rule s many burdensome requirements, such as reporting on 65 quality measures, physicians simply would not be able to make CMS planned ACO program work, said Dr. Peter Carmel, the president of the American Medical Association, wrote in November on his blog, On the Road, after CMS issued its new rules on ACOs. The AMA and Dr. Carmel now believe doctors will at least consider participating in ACOs. CMS also expects about two million seniors enrolled in the Medicare program to have doctors who will be participating in ACOs that have a contract with CMS. But even if physicians don t participate voluntarily in the ACOs contracting with Medicare or an effort like the Advocate-Illinois Blue Cross program, analysts don t see today s current system that pays for each treatment or procedure as an option in the future. Clearly, the government and insurers have decided that physicians will not be paid for services rendered, physician blogger Dr. Kevin Pho, who writes on his site KevinMD said in a post last year. Physicians will be paid based on patient outcomes and will share in any losses insurers sustain due to poor patient outcomes. There are going to be quality indicators and physicians with high quality scores will be paid more than those with low scores. Doctors with lower scores might find themselves outside of networks like those being pursued by Illinois Blue Cross. But Illinois Blue Cross is also working on other arrangements with smaller medical care providers to align incentives, Dr. Sarran said. By doing so, we allow providers to share in the upside. Although not all arrangements with providers will be through ACOs, Illinois Blue Cross has negotiated with 75 medical group entities from large groups to independent practice associations through its HMO plans, HMO Illinois and Blue Advantage. Insurance companies are under more pressure to spend money on quality medical care rather than quantity. Another part of the Affordable Care Act requires insurance companies to spend at least 80% of their premium dollars on medical care in health plans they will be selling on state-regulated exchanges. The health law calls for such exchanges to be operational by 2014 when more than 30 million Americans who don t have medical care coverage will be eligible for subsidies to buy private insurance. Doctors will be held more accountable no matter how health care reform takes shape, Dr. Sacks said. If a doctor has patients going into the ER for asthma, there perhaps needs to be more education to that doctor about asthma, Dr. Sacks said. Care is more cost-effective and efficient when done with the same physician team. Bruce Japsen is an independent Chicago health care journalist. He was health care reporter at the Chicago Tribune for 13 years and is a regular television analyst for WTTW s Chicago Tonight, CBS WBBM radio and WLS-News and Talk. He teaches health care writing at Loyola University Chicago and has taught in the University of Chicago s Graham School of General Studies medical editing and publishing certificate program. He can be reached at 14 Chicago Medicine April 201 2

17 Social Practice How and why you should use social media in your practice by Howard Wolinsky a DaY IN THE LIFE of the medical corner of social media on a late summer day in 2011: Westby Fisher, MD, director of electrophysiology at NorthShore University HealthSystem in Evanston, has posted an amusing item at his Dr. Wes blog at com about an 81-year-old woman who had the words Do Not RESUSCITATE tattooed on her chest to make her intentions known. He added a poll to his site where doctors can vote on whether they would continue or stop CPR/ACLS if they encounter a cardiac arrest patient with a DNR tattoo and no family available. Kevin Pho, MD, a Nashua, NH, internist with possibly the biggest following online, is posting on his Facebook fan page a link to a blog entry by George Lundberg, MD, MedPage Today Editor-at- Large and former editor of JAMA, naming the most powerful people in American medicine. Dr. Pho, who often comments on medical issues as well posting reports from other physicians gets more than 500,000 views per month at his blog and has over 100,000 followers on Facebook, Twitter, LinkedIn, and Google+. He blogs at Vineet Arora, MD, an administrator at the University of Chicago Pritzker School of Medicine, leads readers of her Twitter feed to a New York Times article on how medical practices are working on better ways to serve their patients and bottom lines. Dr. Arora also blogs at FutureDocs ( about medical careers and ways to improve medical education and patient care. You d have to be a hermit in a Himalayan cave to be unaware of social media. Started in 2004, Facebook is the subject of a Hollywood movie and book. It has attracted 750 million members with women age 50 and over as the fastest growing demographic. The Pew Internet and American Life Project reported recently that half of American adults use social networks. They include your family, friends, your patients and probably you, at least to keep up with family and friends. Hospitals, medical practices, and solo practitioners are making their presence known with Evanston s Dr. Westby Fisher posted an item on his blog about an 81-year old woman who had the words Do Not RESuSCITaTE tattooed on her chest to make clear her intentions. Facebook sites and messages from the microblogging site Twitter. Social media include services and sites that link people with similar interests, enabling them to interact over the Internet and share their thoughts, activities, photos, links and videos. Not about Blogging Your Breakfast Social media isn t about sharing what you had breakfast unless that s all you want it to do; maybe you had Bananas Foster French toast. It s about sharing lives and building online communities. Dr. Fisher, who trained as a biomedical engineer, found that social media, including his blog, which he started in 2005, and later, Twitter, fed his inner nerd. To me, the Internet is an incredible forum to discuss the varied, complicated, and even ridiculous aspects of health care. Information moves so quickly now that keeping abreast of change has become difficult. The number of medical journals have expanded so dramatically in my short career that it is challenging to keep up with the voluminous information flow, he explained in his blog. Thanks to the wonders of RSS (Really Simple Syndication), I have found that blogging has permitted me to stay abreast of thoughts and trends in medicine far better that I ever could with reading a small sampling of my field s literature. (I mean, there are so many journals and so little time! ) Dr. Pho started blogging in 2004 to help patients find reliable medical information online. It has become his passion. He devotes two or three hours a day to writing April

18 SocIAl PrActIce often commenting on medical issues, as well as posting reports from other physicians, internist Dr. Kevin Pho gets an astonishing 500,000-plus views per month at his blog. and editing while maintaining his full-time medical practice. His blogging lead to a monthly commentary in USA TODAY. He contends that all physicians would benefit from using social media whether writing a blog or establishing a fan page on Facebook or tweeting to express their views on medical developments. At the very least, he said, physicians should check out their online reputation. (See accompanying story.) Patients are going to Google you. You need to know your digital footprint, he said. Dr. Arora, associate program director for the internal medicine residency and assistant dean of scholarship and discovery at the University of Chicago, took an interest in social media when she saw so many students and residents using Facebook and blogs in A hospitalist, she had published frequently on medical education and patient safety issues. A friend in health information technology urged her to use social media to reach audiences she otherwise might not, including patients, government organizations, foundations, and the mainstream media. Feeling the Pulse Through Twitter Twitter happens to be my gateway to social media. That s how I got involved, but then I was able to learn how to use other social media through my associations with 16 Chicago Medicine April people I met on Twitter, she said. She said Twitter and blogs have helped her feel the pulse on fastchanging areas she s interested in, such as health care reform. Through Twitter, she met an instructional technologist from another medical school who taught her how to incorporate into her class social media, such as Wikis websites that enable the creation and editing of interlinked Web pages via a Web browser. Working with other physician educators she met through Twitter, Dr. Arora created a social media workshop, using Google Docs, a free Web-based text editor, which allows a group to edit a document. One of the greatest things about Twitter and social media is that you get connected to a lot of people who share your interests and your passions, but may approach a problem from a worldview different than your own. You might learn things you did not know about, she said. She recommends that physicians restrict contact on personal pages at Facebook to close friends and family not patients. She said there needs to be a boundary between physicians and their patients. To maintain that personal boundary, she does not invite patients or students to be Facebook friends. However, she said physicians or a medical practice could create a basic fan page on Facebook, where they share information about hours, new personnel, public health information such as availability of flu shots, and comments on news. She said physicians potentially could use Facebook or other social media to engage their patients. She mentioned a Texas oncologist who uses Facebook and Twitter to reach out to cancer patients. Online patient support groups exist for people with rare diseases; patients have used social media to create a clinical trial. Dr. Arora noted that social media are not for everyone. Right now, it s still a new technology and people are very much trying to figure out what the boundaries of the technology should be. Given the statistics showing how many people are on Facebook and social media and using them to share information, I think that it s important for more doctors to join the dialogue, said Dr. Arora. at the very least, physicians should check out their online reputation. Patients are going to Google you. You need to know your digital footprint But she warned that the reimbursement system is not set up to pay physicians for using social media. The incentive is to bring patients in and see them in your office, she explained. Possible Downsides There can be risks. Dr. Arora said residents and medical students who grew up with Facebook and other social media can encounter problems if they do not maintain professionalism. Friending patients is something

19 SocIAl PrActIce they should avoid. Medical schools have also expressed concern over students who violate professional boundaries or inappropriately showcase pictures or videos that don t portray their medical training in a positive light. Students are moving from a low-stakes undergrad world into a highstakes professional world where posting their opinions and comments about patients could land them in trouble. There have actually been cases (at other institutions) where patients have refused to be treated by a resident physician because they saw their Facebook profile and saw some inappropriate pictures, Dr. Arora said. I have been involved in helping teach students and residents about the importance of setting their profiles to private. She said physicians and students using Facebook should be careful not to violate HIPAA privacy rules. Twitter and Facebook are not be used for private conversations that should be HIPAA protected, she said. Chris Martin, MPH, who blends traditional medical public relations and social media in his Chicago practice, said, The average physician is not using social media in her practice. He said they are missing an opportunity to reach out to and educate patients and potential patients as well as to build their practices. He said physicians can use social media to keep patients up-to-date on breaking medical news, giving take on the latest study from the New England Journal of Medicine or a drug recall, as well as presenting news about their practices, such as new hours, the addition of new staffers, or the availability of flu shots or other public health messages. Physician involvement can be as big or small as the doctors want. The physician or a staffer can handle social media, or they can pay an expert. practices compared with Yellow Page advertising, he said. But they have to realize, there is a time commitment involved, and time is money. Physicians shouldn t be fooled into thinking that because it s free to set up a Facebook, Twitter, or Tumbler account, that there are no costs. The costs just aren t as easily identifiable as when you cut a check for the Yellow Pages or an ad in the local paper. Those costs are real. The cost is the amount of time a physician or staff person devotes to blogging or hiring an outside expert to establish and manage a social media program. Martin said he would recommend a six-month public relations and social media program for small groups, costing $1,000 to $2,000 per month. While advertising in the Yellow Pages allows physicians to have an arm s length relationship with patients, social media demands that physician get involved. It s a conversation, he said. Some people in health care might have trouble adjusting to this. Dr. Pho said social media will become increasingly important for the generation of patients and physicians who grew up on MySpace, Facebook, and Twitter. These doctors are going to embrace it more because they realize the power behind it, he said. And patients increasingly want an Internet-savvy doctor. Howard Wolinsky is the former medical and technology reporter for the Chicago Sun-Times. He previously worked as a staff writer for American Medical News as an instructor in the graduate program at Northwestern University s Medill School of Journalism. Including Social media in a marketing Plan Martin said physicians ought to consider social media as part of a marketing plan. Some larger hospitals may provide physicians on staff with social media support as part of their marketing, promotion, and referral programs. But he said physicians in smaller practices ought to address social media on their own. More and more, social media makes sense financially for small u of C s Dr. Vineet arora helps educate young physicians by blogging about medical careers and ways to improve medical education and patient care. April

20 The Ratings Game Physicians: Watch your online reputation by Howard Wolinsky You may not know it, but patients, especially younger ones, may be rating you online. Using social media, from Facebook to Yelp, they may chat with friends or rate you along with their favorite eateries, on the usual physician rating suspects such as Vitals. com and Today s patients under age 50, certainly under 40, don t write letters (to complain). They go for revenge. One star reviews online, said John Luginbill, a marketing expert and CEO of The Heavyweights in Indianapolis. There is no such thing as a 20-, or 30-, or 40-year-old woman who isn t reading about her doctor before she makes a decision about who her provider should be. Word of mouth a referral from another physician or a recommendation from a new patient s friend or neighbor is how patients traditionally heard about you and your practice. Now word of mouth has spread from face-to-face or phone conversations to the Internet, where positive and negative comments are amplified on a digital megaphone and may last forever. Luginbill, founder of, an online service to monitor and manage physicians and health institutions digital reputations, said: The only accreditation today s patients trust are the opinions they hear from friends and other patients. RepuChek was created since 80% of word-of-mouth recommendations are occurring online. Kevin Pho, MD, an internist from Nashua, NH, a well-known blogger, said physicians ought to increase their awareness of their social media footprint: A lot of physicians don t know that people write about them. But they need to know. The growth of social media and its impact on physicians has not gone unnoticed by policy-makers in the profession. At its meeting Nov. 8, 2010, in San Diego, the American Medical Association adopted guidelines to help physicians understand and deal with social media. Noting that once posted on the Internet, information is likely to be there permanently. The AMA urges physicians to routinely monitor their own Internet presence to ensure that the personal and professional information on their own sites and content posted about them by others is accurate and appropriate. The AMA added that physicians should recognize that actions online and content posted can negatively affect their reputations among patients and colleagues, and may even have consequences for their medical careers. (For more on the guidelines, go to: professionalism-social-media.shtml) Vineet Arora, MD, assistant program director for residency at the Pritzker School of Medicine at the University of Chicago, who is well-known in social media circles, said: We teach our medical trainees that they need to police their digital image and get out there and make sure they know what s being said. Google Yourself An obvious stop is the search engine Google. Just go to and type your name and your practice into the search box and see what comes up. You may know about Yelp at for finding restaurant reviews. But did you know how the service promotes itself? Yelp is the fun and easy way to find and talk about great (and not so great) local businesses. Local businesses can mean Patients use of nontraditional means to complain about physicians can include blogs, Twitter and Facebook as well as the rating Web services. your medical practice. And many younger patients especially don t think twice about throwing a rotten tomato at a physician who they feel mistreated them Or you may know Angie s List at as a great place to find detailed reviews on roofers, plumbers, and house cleaners. Angie also carries ratings for physicians. Almeta E. Cooper, former general counsel for the Ohio State Medical Association and now associate vice president of the office of legal services at the Ohio State University Medical Center in Columbus, Ohio, said, patients use of nontraditional means to complain about physicians can include blogs, Twitter and Facebook as well as the rating Web services. Cooper, who spoke on this topic at the American Bar Association conference in Chicago recently, said this poses special problems for physicians. If you re complaining about your windows, about the person who installed them or about the manufacturer, the installer or manufacturer can respond and say, No, I installed those windows correctly. But a physician who has to protect patient confidentiality can t really respond and explain the patient s medical care and treatment. Physicians aren t really in a position to comment or really be able to defend themselves because of the physician s ethical and legal obligations to the patient, she said. Cooper said large medical institutions, such as OSU Medical Center, have social media experts on staff to monitor tweets and Yelp for gripes and complaints and then try to resolve the issue with patients. She said, It s a little easier for us as a medical center because our presence locally and nationally is very large and there are so many good things always coming out about the medical center therefore one individual with a complaint doesn t have quite the same impact as if you re an individual physician and someone is specifically making a negative comment about you as an individual physician. Dr. Pho said there is not a lot that physicians can do about negative reviews. A few doctors have tried suing patients. That s generally not a good idea, he said. Getting Proactive Luginbill recommends that physicians take a more proactive stance with bad reviews. For example, he said, if a doctor has been criticized on Yelp, he can contact the patient and discuss the issue and if the patient is satisfied he may take down or modify the complaint. Another approach, he said, is to contact Yelp and ask to take control of the page. They ll give it to you immediately, he said. He said the doctor can update the site by adding his practice s hours and photos. He said once the physician controls the site, he can complain to Yelp if he feels that a review is abusive or contains 18 Chicago Medicine April 201 2

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