Individual Health Insurance

A few weeks ago we talked about how to increase professional referrals to your practice. Developing this referral source is essentially a networking exercise, but the point of the post was to provide a framework in which to do it without feeling weird, creepy, or uncomfortable.

I know there are a lot of alternative and complementary practitioners who are involved with networking groups like BNI. While I don’t generally promote those groups a great deal, I read a fantastic tidbit from Ivan Misener, the founder and CEO of BNI, in a piece on Entrepreneur.com:

3. Word-of-mouth is more about farming than it is about hunting.

Building your business through word-of-mouth is about cultivating relationships with people who get to know you and trust you. People do business with people they have confidence in. One of the most important things I’ve learned in the past two decades is this: It’s not what you know, or who you know, it’s how well you know them that counts. [emphasis mine]

It’s a great metaphor for the development of your professional referral base. The approach we recommend - of slowly gathering background and connections before you approach someone - is aboutchoosing to farm relationships. Nurture them gradually in the form of inquiry, research and contemplation. Plant them, water them, and watch them grow, but don’t harvest them until they’re ready.

And whatever you do, don’t hunt them. That’s what everyone else is doing because they haven’t yet realized that you can only eat prey once, but you can harvest a garden forever.

Related posts:

1. New Patient Referrals: The 5 P’s

A study presented at a recent American Heart Association Conference (www.americanheart.org) has found that candy in wrappers might help indulgers eat less as opposed to eating unwrapped candies.  Researchers found that people who ate candies and kept the wrappers in plain sight ate only about half as many as those who did not.

Lead author Brian Wansink (author of Mindless Eating, www.mindlesseating.org) says, “Having a visual reminder of how much [you eat], keeps you honest and eating less.  Your stomach can’t count, but your eyes can when they see the empty wrappers.”

It also helps to keep the candy in a less convenient location as opposed to a more convenient location, Wansink says.  So for instance, in the office, you wouldn’t want to keep the candy on your desk where it’s easy to get to.  Move it at least 5 or 10 feet away so that you have to get up and walk for your treats.

Not sleeping well can lead to problems, especially for older adults, research has found.  Depression, attention and memory problems, excessive daytime sleepiness and nighttime falls can all occur as a result of poor nighttime sleeping.  According to the American Academy of Sleep Medicine, some of the more common sleep disorders in older adults include:

• Insomnia, which affects almost half of adults 60 and older.
• Obstructive sleep apnea, which can elevate the risk for high blood pressure, stroke, heart disease and cognitive problems.  Snoring, a symptom of OSA, is a very common condition affecting nearly 40 percent of adults, and is more common in older people.
• Restless legs syndrome, which can cause people to jerk and kick their legs every 20 to 40 seconds during sleep, is evident in almost 40 percent of older adults.

Follow these tips to get a better night’s sleep:

• Establish a routine sleep schedule.
• Avoid using the bed for anything other than sleep and intimacy.
• Avoid substances that disturb your sleep, like alcohol or caffeine.
• Avoid daytime naps.  If you must take a nap, limit the time to less than one hour and no later than 3 p.m.
• Stick to rituals that help you relax each night before going to bed.  This can include things like a warm bath, a light snack or a few minutes of reading.
• Don’t take your worries to bed.  Bedtime is a time to relax, not to hash out the stresses of the day.
• If you can’t fall asleep, leave your bedroom and engage in a quiet activity.  Return to bed only when you are tired.
• Keep your bedroom dark, quiet and a little on the cool side.

Washington -- Funding levels for health information technology programs in President Bush's fiscal 2009 budget have come under fire in recent weeks from some analysts and Democratic lawmakers. They say the proposed investment isn't enough to advance the administration's goal of widespread electronic health record use by 2014.

The $3.1 trillion budget plan would boost spending for the Office of the National Coordinator for Health Information Technology by 9%, or $5.5 million, to $66.1 million. It also proposed keeping HIT funding for the Agency for Healthcare Research and Quality at last year's level of $44.8 million. AHRQ uses these funds to test HIT systems and recommend best practices. The agency would continue focusing resources on information technology investments that enhance patient safety.

At a Feb. 14 Senate Budget Committee hearing on HIT funding, Sen. Sheldon Whitehouse (D, R.I.) criticized Bush for allocating so little money to the technology coordinator's office. Widespread adoption of HIT could save $81 billion, he said, yet the president is proposing much less to achieve it. "If you could make $81 billion and get a 100% payback, that gives you an idea of how off we are in magnitude.

"Despite positive rhetoric and small steps forward, President Bush has largely squandered the opportunity to make meaningful progress on the development and implementation of a nationwide information technology system," he added.

Sen. Kent Conrad (D, N.D.) identified widespread adoption of HIT as a critical way to control health care costs. The U.S. spends 16% of its gross domestic product on health care, a figure which is expected to rise to 37% by 2050. The private sector will be overwhelmed by health care costs if they are not contained, Conrad said.

The lone Republican at the hearing, Sen. Judd Gregg (R, N.H.), did not comment on the president's HIT budget but noted the difficulty posed by the lack of interoperable electronic medical records. Gregg said he had to request federal funding for an interoperable system at a New Hampshire hospital where the systems were so complicated that the staff could not communicate from one department to another.

A Government Accountability Office report released at the hearing concluded that while the Dept. of Health and Human Services has made progress pursuing Bush's 2014 goal, it has not developed a national strategy to reach it. "Given the many activities to be coordinated, such a national strategy is essential," noted Valerie C. Melvin, GAO's director of human capital and management information systems issues, in written testimony at the hearing. Melvin noted that the federal health technology office has prepared a draft health IT strategic plan and expects to release it this spring.

Bush budget documents say HHS concluded that it missed its fiscal 2007 goal of having 18% of physicians adopt minimally functional electronic medical records. According to the department, only 14% did so.

Analysts debate commitment to HIT

HIT experts projected different views about the significance of the budget.

Although the funding level could be higher, Bush's proposal is a good sign that he counts on the next president continuing the technology office's work, said Don Asmonga, director of government affairs for the American Health Information Management Assn.

14% of doctors adopted minimally functioning EMR systems in 2007.

Bush could have recommended zeroing out the office, he said, but the fact that he proposed to fund it through 2009 and into another administration shows his commitment. The office's proposed budget is adequate for current programs, he added.

"It's more of a continued push for coordination to build the infrastructure and standards for future implementation," Asmonga said.

But Laura Adams, president and CEO of the Rhode Island Quality Institute, said the proposed funding level for the HIT office is disappointing. The institute is a public-private initiative to build a health care information exchange in the state. "Five million is woefully inadequate for the promise of what HIT can bring," she said.

The increase should be four or five times higher, given what the return on investment could be, Adams explained. Extra money could fund more research and development projects at the local level.

"It's hard for us to set up a nationwide HIT system if we don't know how to do it at the local level," she said. "There are a lot of local and state HIT projects that struggle to find funding and shouldn't be."

AHRQ's budget should have been tripled, Adams added. The extra money could have been spent on understanding how new technology can be applied at the point of care and developed so every patient receives it.

In the HIT office's budget, Bush proposes a $7.7 million increase, to $21.5 million, for standards harmonization so IT systems can exchange data across different health care settings. The extra money would support the American Health Information Community, the federal advisory board established in 2005 to recommend ways for accelerating technology adoption. The funds also would launch a successor to it once AHIC makes a planned change to become a private-sector organization this fall.

The budget also would increase funding for the Nationwide Health Information Network by $6.8 million, to $26 million. The program will fund nine health information exchanges across the U.S. and develop the best way for consumers to access electronic medical data in a health information exchange. HHS intends to test these entities in September on their ability to work with each other and federal agencies.

But the proposed budget would cut funding for privacy and security programs by $7.6 million, to $10.6 million, because the national coordinator's office will shift away from funding projects addressing barriers to exchanging HIT across states to evaluating such initiatives. The financial blueprint also would cut spending for operations by $1.4 million, to $8 million, through more efficient use of contractors.

Washington -- President Bush's legislation to slow Medicare spending is heavy on provisions related to doctors -- from public quality rankings of physicians in five years to instituting pay-for-performance. But the bill doesn't address Medicare physician pay cuts due to take effect July 1.

James King, MD, president of the American Academy of Family Physicians, said Medicare pay reform needs to be a higher priority for the administration. "They have to come to terms with how they're going to pay physicians, where the money is going to come from and [how to] pay toward what they want to accomplish." The American Medical Association is working to prevent the 10.6% pay cut scheduled to kick in for the last six months of 2008.

Bush was required by the Medicare Modernization Act of 2003 to offer a proposal to rein in program spending. The act mandates that the president submit a Medicare reform plan if, for two consecutive years, 45% of the program's funding was projected to come from general tax revenues instead of dedicated payroll taxes or premiums within six years. The Medicare trustees projected in 2006 and 2007 that this would happen.

"This legislative package ... would take the first step of responding to the funding warning in the trustees' 2007 report," wrote Health and Human Services Secretary Mike Leavitt in a letter to House and Senate leaders. "Perhaps more importantly, it would begin to address the long-term challenge and lay the foundation for the comprehensive Medicare reforms that are necessary to strengthen and improve the program for future generations."

The bill, released Feb. 15, calls on Leavitt to work toward wider adoption of electronic medical records. It does not elaborate on Bush's long-standing goal of having a national health information network by 2014.

The provision on quality rankings would require HHS to publish reports on physicians, hospitals and health plans by 2013 for 50% of treatment paid for by Medicare.

The bill, called the Medicare Funding Warning Response Act of 2008, also reintroduces a medical liability proposal similar to a measure Congress failed to adopt in 2006. It would cap noneconomic damages at $250,000 and limit punitive damages to the greater of $250,000 or two times noneconomic damages. Leavitt said this would limit Medicare spending by discouraging defensive medicine.

Bush also proposes increasing Part D premiums for the wealthiest 5% of the 25 million drug program enrollees, starting with those earning $82,000 per year and couples making double that. AARP Advocacy Director David Sloane said the group objects to increasing beneficiaries' Part D cost sharing, especially because income levels used to calculate their new costs wouldn't be adjusted for inflation.

Congressional reaction to Bush's measure was split. Rep. John Dingell (D, Mich.), chair of the House Energy and Commerce Committee, said the bill wouldn't improve Medicare but would make seniors pay more for it. He also said the 2003 Medicare reform act's 45% threshold is an arbitrary Republican scare tactic designed to justify program cuts.

Sen. Max Baucus (D, Mont.), chair of the Senate Finance Committee, welcomed some of Bush's ideas. Baucus said he will not include the increased Part D cost sharing or medical liability proposals in Medicare reform legislation he's planning to introduce this spring. But he said he sees room for bipartisanship on better linking cost and quality in Medicare treatment.

"Value-based purchasing and health information technology are both smart targets for reforms in Medicare right now," he said. "But in the end, dealing with the rising cost of Medicare will mean controlling costs across our health care system as a whole."

Rep. Joe Barton (R, Texas), the senior Republican on Energy and Commerce, said the Bush bill deserves hearings. "The politically charged swirl of the 2008 presidential election campaign doesn't lend itself to good policymaking, but our committee should take the lead in doing what can be done -- hearing experts, establishing facts and exploring possibilities."

At press time, the Congressional Budget Office hadn't released an estimate of the bill's savings. Leavitt said the Part D cost-sharing provision would save $3.2 billion over five years by lowering federal premium subsidies. The average Part D plan costs beneficiaries $25 per month, said Centers for Medicare & Medicaid Services spokesman Jeff Nelligan.

Performance pay is complicated

The pay-for-performance provision in Bush's plan calls for HHS to use a portion of existing Medicare funding to reward doctors, hospitals and others based on "well-accepted" quality and efficiency standards. This type of reform is easier said than done, said the AAFP's Dr. King.

To start, gathering the data needed to support pay-for-performance won't be easy without electronic medical records, and EMR adoption won't happen quickly without financial help for small group practices, Dr. King said. The AAFP estimates that 50% of its members will have an electronic records system by the end of 2008, but most of the rest are physicians working alone or in small practices who can't afford these systems.

HHS also must coordinate with private insurance companies on quality standards, Dr. King said. "We really feel the parameters need to be more global. I don't want to do one for Medicare, another one for Blue Cross Blue Shield and another one for Cigna."

Finally, HHS needs to consider using the carrot of additional payments for meeting quality standards and not just the stick of reducing pay to physicians who don't, Dr. King said.

The president's bill would do the latter. "We think that's just inappropriate," Dr. King added.

AMA pay-for-performance principles say programs should ensure quality of care, foster the patient-physician relationship, offer voluntary physician participation, use accurate data and fair reporting, and provide fair incentives.