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Leigh Page
Leigh Page is a health care writer in Chicago, Ill.

In Push for Quality, Ophthalmologists Are Seeing Increased Scrutiny
Over the past 10 years, the focus on improving quality and patient safety has been worked into almost every aspect of health care. The maintenance of certification (MOC) for ophthalmologists is no exception. But until recently, the MOC process for ophthalmologists has been difficult and challenging.

When MOC was introduced in 2001, some ophthalmologists became alarmed and angry. The first step of the ophthalmic MOC was to replace an open-book exam for holders of time-limited certificates with a closed-book, proctored exam. Diplomates were furious and the American Board of Ophthalmology (ABO) was inundated with protest calls and letters, the board reported last year, because only holders of time-limited certificates, first issued in July 1992 and good for 10 years, needed to take the recertification exam. Those holding lifetime certificates, issued before 1992, do not have to go through the MOC process.

Online Physician Reviews Target Ophthalmologists Both Good and Bad
With dozens of Web sites to choose from, physician reviews are getting to be ubiquitous. In 2007, 22% of Californians said they had looked at physician rating sites, up from 14% in 2004, according to a Harris Interactive poll commissioned by the California HealthCare Foundation. In addition to sites limited to rating physicians, such as Book of Doctors (www.bookofdoctors.com), Find-ADoc (www.findadoc.com), and MDJunction (www.mdjunction.com), there are sites such as Yelp (www.yelp.com), Insider Pages (www.insiderpages.com), and Judy’s Book that post ratings on all sorts of businesses, including doctors.

CKD Clinics Spreading Slowly
Nelson Kopyt, DO, believes CKD clinics using a team of caregivers to care for patients with chronic kidney disease will help improve the quality of care these patients receive. He also believes CKD clinics can help expand access to care for patients with CKD. Since opening a CKD clinic in 2002, the nephrologist has made presentations for the National Kidney Foundation on the benefits of such arrangements. Kopyt’s practice, Nephrology Hypertension Associates of the Lehigh Valley, in Easton, Pa., has six physicians. Five work full-time and one is part-time.

Some clinics operate in large practices or academic settings, and a few smaller private practices also have started CKD clinics. Although Kopyt acknowledges that no one knows how many CKD clinics are operating nationwide, these arrangements have not caught on widely. “My impression is that they have not taken off as we had hoped,” he comments.

Why Surgeons Hesitate to Bill for IOLs
Three years after Medicare made it possible to insert presbyopia-correcting intraocular lenses (IOLs) for cataract patients and bill patients for the cost, many cataract surgeons are still holding back, according to several eye surgeons who advise colleagues on using the new lenses.

Jay S. Pepose, MD, director of the Pepose Vision Institute in St. Louis, says many cataract surgeons are still undecided on whether to use the new technology that could free certain cataract patients from eyeglasses in part because they are reluctant to bill these patients.

Optometrists Bolster Patient Care
For Ronald Barnet, MD, employing optometrists in ophthalmic practices is not new. Barnet’s practice in Phoenix has been employing optometrists for at least 25 years. But for many ophthalmologists, the practice of working with optometrists is somewhat novel. The arrangement called, “integrated eyecare delivery,” is being touted as a way to make ophthalmologists more efficient and to help them address predicted workforce shortages.
In Barnet’s practice, 17 ophthalmologists can handle 9,000 cataract surgeries each year because 19 in-house optometrists help them with pre-operative evaluations and post-operative care. “Ophthalmologists still see the patient once before surgery and handle the first post-op visit, but an optometrist spends more time with patients and tends to be closer to the patient than the ophthalmologist,” Barnet explains.
“We all have to find a way to deliver a high quality of health care in the most efficient way,” Barnet says. By using clinicians with an optometry doctorate (OD), ophthalmologists can then focus on what no one else can do: the surgery. “I’ve always regarded ophthalmology as a surgical specialty,” Barnet adds. But even though ODs have been working in practices such as Barnet’s for many years, Barnet still finds some ophthalmologists are uneasy about the arrangement. The critics argue that integrated eyecare delivery is a kind of Faustian bargain that is bad for the specialty. In exchange for boosting surgery numbers, they argue, the ophthalmologist cedes control of care to a less qualified professional. Barnet disagrees.

Retinal Surgeons See Benefits in ASCs
In the past 20 years, while general ophthalmologists were building hundreds of ambulatory surgery centers across the country for cataract patients, few retinal surgeons were involved in ASCs. Due to concerns about the intensity of their procedures and low reimbursements for their work in ASCs, retinal surgeons seemed committed to working in hospital operating rooms. But today, as retinal procedures become easier to perform in ASCs and reimbursement is rising, retinal surgeons are moving cases out of hospitals and into ASCs. Also, retinal surgeons have heard from cataract surgeons who have built ASCs that the development can be time-consuming, expensive, and financially risky but is well worth the effortonce completed. “It’s going to take longer than you think,” cautions Larry E. Patterson, MD, a cataract surgeon in Crossville, Tenn., who has opened two ASCs. “Once the ASC is in operation, it’s more convenient and you have more control,” he adds. “You can choose when you want to do surgery.” Leo T. Neu III, MD, a retinal surgeon who has invested in an ASC, took advantage of a rare opportunity. He and three cataract surgeons bought an existing facility in Springfield, Mo., from a retiring surgeon in 1999. Until the rise in reimbursement this year, Neu was barely breaking even, he explains. The financial considerations notwithstanding, Neu was motivated to partner with the cataract surgeons because he wanted to work more efficiently. “Retinal surgery is more time-consuming in the hospital, and your case can always get bumped for an emergency,” he explains.

Physicians Find Many Ways to Increase Patient Satisfaction
When patients stop coming back, ophthalmologists often seek out consultants such as James A. Muschler. “Where did we go wrong?” they ask. The answer is usually quite simple, says Muschler, a principal with the ARSI Group, practice management consultants in Itasca, Ill. The practice did not listen to its patients, didn’t explain enough, and made them wait too long. These are just a few of the problems that are common in ophthalmology and other physician practices. Most physicians have to reach a crisis such as a marked drop in appointments before they care about patient satisfaction, Muschler explains. William B. Rabourn, Jr., managing principal of the Medical Consulting Group in Springfield, Mo., agrees, saying that ophthalmologists will often make technical competence their first priority, and many of them will not give much attention to patient satisfaction until the number of patients declines. “When patients don’t like what they see, they may say nothing,” he says. “They just vote with their feet and their pocketbooks.” But once ophthalmologists exhibit a concern for patient satisfaction, they may be surprised by the variety of benefits that patient-centered care brings to the practice, Muschler adds.

Take Steps to Avoid Claim Denials
Few medical practices can afford to give away income as a result of claims denials. Yet, some practices ignore denied claims, finding the cost and effort of pursuing them not to be worth the time and expense. Consultants estimate that the average practice loses about 10% of gross billings due to lost, forgotten, or incorrectly prepared charges. Experts estimate that reviewing, revising, and resubmitting claims costs at least $4.40 for each rejected claim. “For this reason, it’s very important to make sure claims are accurate the first time around,” says Roberta L. Buell, a reimbursement consultant in Sausalito, Calif.

Hand-Helds Help Capture Charges
A few moments each day is all it takes Michelle A. Smith-Levitin, MD, to do a small task that adds value to her practice. While standing in a grocery store checkout line or waiting to pick up her children after soccer practice, she can use her personal digital assistant (PDA) to enter patient charge information.

Using advanced portable software, it takes her only about 30 seconds to enter codes for each patient. Several taps of the stylus on the screen quickly lead the user through queries to create highly accurate ICD9 and CPT codes.

Experts Suggest Asset Protection Methods
One problem with developing an asset protection plan is it can be difficult to know which assets need protection when no threats are looming, experts say. That’s why the best time for ophthalmologists to develop an asset protection plan is when no threats are pending, such as a malpractice lawsuit, divorce, or creditor pressing for a large amount owed.
If an ophthalmologist comes to Robert L. Bolick, an asset protection attorney in Las Vegas, when assets are threatened, “I tell them it’s too late,” he says. Even when a malpractice lawsuit is just a remote possibility, a court may view a transfer of assets as fraudulent and thus could make them available for creditors. A Variety of Instruments In other words, the only time to develop such a plan is when a practice is not under a threat. At this time, the ophthalmologist will need to meet with an asset protection adviser and discuss what could happen and what protections are available.

What a Chart Audit Will Tell You
Coding claims correctly in a nephrology practice is a continual learning process that involves developing an expertise with all the fine points of coding and then adjusting to changes in coding rules as they are made. That’s why coders and billers in nephrology practices do routine internal audits. Regular audits can help a practice assess coding accuracy and help physicians and administrators identify ways to improve coding.
Practices that routinely audit their claims will likely see an overall rise in their billing for evaluation and management codes (E&M), says Mary McCloskey, the billing manager at Nephrology Associates, a practice of 10 nephrologists in Wynnewood, Pa., that routinely does self audits.

Recruiting the Best Nephrologists
When a nephrology practice is growing, the partners must work harder and at the same time recruit new practitioners to take up the slack. But before adding staff, nephrologists should consider the options carefully, because new staff will shape the practice’s future direction, says Martin H. Osinski, president of Nephrology USA, a recruiting and consulting firm in Miami. Practices have several options, says Osinski, who has 20 years of experience in nephrology recruiting. They can hire a young nephrologist out of fellowship training, a seasoned nephrologist, or a midlevel practitioner, such as a physician assistant or nurse practitioner. This third option is becoming increasingly popular. A growing number of nephrology practices are turning to midlevel practitioners, rather than hiring a new physician. With supervision, midlevel practitioners can assume some of the work that physicians would do otherwise, such as primary care, following up on office visits, and working with dialysis patients. They also staff chronic kidney disease clinics and vascular access centers.

Hospitalists Help Improve Quality
This article looks at how hospitalists programs are improving quality of care for patients, as well as offering physicians a new career option.

Hospitalists Save Groups Time, Money
This article discusses the benefits hospitalists can provide to PCPs in terms of reducing costs, increasing efficiency, and offering the potential to increase income (by freeing up time otherwise spent on visiting their hospitalized patients).

California Groups Take Businesslike Approach
This article discusses the impact on California medical groups of the financial reporting system introduced last year by the California Department of Managed Health Care.