From Tom's Desk

How would you feel if you were caught up in a compliance enforcement matter—not particularly egregious but one in which the regulator required “a body” to take the fall. It’s everyone’s compliance nightmare and the stuff of thrillers and B movies.

But for Howard Root it was a reality.

He was the founder and CEO of Vascular Solutions and he found himself in just that situation.  Actually innocent of any regulatory breech, he and his company ended up in the crosshairs of the Justice Department.  No negotiated settlement was possible without someone going to jail.  In their own words, the Justice Department required “a body.”

Howard Root lays out his horrific experience in his new book, Cardiac Arrest—and it’s a chilling must-read for anyone who is subject to compliance enforcement.

Root risked a much longer prison sentence rather that buckle under and admit to something he didn’t do.  Unlike most apologist’s tomes, this one is not some self-serving, after-the-fact justification of actions taken.  It’s a well researched, page-turning thriller, heavily documented and endorsed by the journalists and observers directly involved with the case.

The only reason you’re hearing of him now is that he had five years, $25M and the backing of his board to defend himself. 

If you were thrust into the same situation, would your organization defend you with such vigor?

Something to think about next time you’re asked to push the regulatory envelope.

You Should Know...

Two pieces of news flew under the radar this week.  First, financial reports from insurance giant Aetna showed that the Federal Government, for the first time ever, had become it’s largest customer.  Second, new data from the Labor Department revealed that the Federal Government now directly insures the health of 119M Americans, crossing the threshold of one-third of the population for the first time in history.

For all the debate over health insurance funding, these benchmarks simply demonstrate once again that the slow transition to a functional single payer system is clearly under way.

We are all government contractors now.  Political advocacy and market share acquisition are paramount, that is until their return on capital declines below real interest rates. Organizations can only invest in so much real estate as the rate of return on servicing patients through them declines into the red.

In such a environment, generating value for patients—not government-defined value but actual, concrete value as the patient defines it—is the long term strategy for success. 

High-Value Insight

Facilities who service patients at a custodial or skilled level of care must periodically submit a document called a “Minimum Data Set”. Among other information, the document includes the diagnostics codes that are part of the patient’s comprehensive care plan.  Mostly derived from physician orders, it’s also is a source of diagnostic codes that the government uses to calculate the patient’s monthly capitation rate under the Medicare Advantage system.

It’s an excellent tool to leverage to make sure you and your organization are capturing all the revenue to cover the care costs of these high risk patients.

Every facility has an “MDS Coordinator” whose job it is to compile and submit this data.  Get to know them.  Understand how they extract the data from their records for compilation and submission.  Give them permission to contact you with questions. Cultivate that relationship.  Then, when you perform your yearly assessments on these patients, take a moment to go over your documentation with them to make sure all the required information is properly handed off.

It might seem like a pain, but the potential for losing valuable information as it moves from your documentation to her MDS is significant.  Sure, your visit documentation will capture the information as well, but the MDS is a very important failsafe. This one step, which really only takes a couple of minutes once a year, is a small price to pay to ensure that you’re collecting all the  available resources for your high-risk patients.

Q&A with Dr. Tom

How can I capture diagnostic codes on patients that never come in to see me?

That’s a tough one.  Much to my chagrin, I was never ever to get 100% of the patients in to see me for a routine visit during a given calendar year, my best was 97%. Nowadays, it’s getting even harder.  Patients are getting constantly pestered by phone, email and internet to get all manner of interventions and they are getting tired of it. The lowest hanging fruit is to target patients who have not been seen because it’s physically difficult to come into the office.  In other words, do a house call.

In a high volume, high overhead fee-for-service world, home visits are a financial loser.  But in a value-based system where the clinician has skin in the game, house calls will generate enormous returns in many different ways.  In fact, you can identify high-performing value-based systems by whether and how often their primes do house calls.

Be careful though, you just can’t show up at a patient’s house and submit a visit.  The patient must be unable to physically leave their abode due to infirmity or the symptoms of that infirmity such as pain.  If you can document that, then you can submit the visit for payment—and all the documented diagnoses that were addressed.

Just as important, house calls are a phenomenal marketing tool. Once the word gets out on social media that you’re willing to do them, your phone will ring off the hook.  And the regulatory limitations will protect you from the expectation that they can be offered routinely.

Safety is always a concern.  HIPPA precludes taking a family member along on a house call, so I will usually arrange to meet a home health nurse or care coordinator at the residence if I am in anyway concerned about the environment I’m entering.

Visiting my patients in their home provided me with an enormous amount of information that helped me care for them more effectively and reduced their care costs. I bonded with my patients, learned about their care givers and made friends for life.  Make your appointments around noon or after five and be prepared for a free meal.

And that’s the most important benefit of making house calls, turning back the clock and once again practicing medicine with joy.