INDIA: A prominent medical organization here has ordered a probe into an allegation that some doctors and agents in southern India have pressured tribal people to sell their kidneys.

The Indian Medical Association’s June 22 move came after the Tribal Protection Council in Kerala state presented victims at a June 18 press conference.

Chemban Kanan told reporters that he sold a kidney for $410 to feed his four children and wife, who had been starving for days. According to him, a local businessman took him to a hospital for the kidney removal, but paid only half the promised amount after the operation.

Kanan said the two doctors “compelled me to convince my neighbors that selling kidneys is the right thing for making money,” he added.

K.P. Manikandan, secretary of the tribal council, said pressuring famished tribals to barter their kidneys for cheap money “is the ugliest form of exploitation.” He said June 20 that they have already recorded 26 cases of kidney sales and are now trying to educate tribal people not to sell their kidneys.

The Indian Medical Association has termed the kidney sales a “highly unethical practice.” Dr. Jose M Malana, the association’s ethics committee convenor, said they would investigate the crime “at any cost.”

“The business involves taking the kidneys of poor tribal people and supplying them to rich patients in [Persian] Gulf countries,” Malana said. He said the association is now trying to find out the hospitals that conducted the kidney transplant operations.

In December, the House of Delegates of the American Medical Association (AMA) unanimously approved a resolution aimed at eliminating from agreements between physician researchers and pharmaceutical companies restrictive clauses that interfere with sharing scientific information. The resolution calls on the AMA to work with other organizations to develop guidelines to accomplish this goal, and for the AMA itself “to protect the right of physician researchers to present, publish, and disseminate data from clinical trials.”

The AMA’s resolution is in line with steps taken in recent years by other professional organizations, research universities, and the federal government to deal with conflicts of interest and bias in scientific research. These include several reports issued by the Association of American Medical Colleges starting in 2001 on individual and institutional financial conflicts of interest in human subject research; regulations adopted or revised by universities to prevent conflicts of interest especially in studies involving human subjects; and new rules announced by the National Institutes of Health (NIH) in February 2005 that, with very limited exceptions, prohibit its employees from receiving compensation of any sort from a company or organization that is an NIH funding applicant, grantee, or contractor.

The AAUP’s 2001 Statement on Corporate Funding of Academic Research, published in the May-June 2001 issue of Academe, emphasized the continuing importance of universities’ having conflict-of-interest policies, and the faculty’s role in their formulation and review of their effectiveness. “Research universities have long collaborated with industry to their mutual benefit,” the report points out, but the relationship “has never been free of concerns that the financial ties of researchers and their institutions to industry may exert pressure on the design and outcome of research.”

Objective. To assess the effects of payment methods on the costs of care in medical group practices.

Data Sources. Eighty-six clinics providing services for a Blue Cross managed care program during 1995. The clinics were analyzed to determine the relationship between payment methods and cost of care. Cost and patient data were obtained from Blue Cross records, and medical group practice clinic data were obtalned by a survey of those organizations.

Study Design. The effects of clinic and physician payment methods on per member per year (PMPY) adjusted patient costs are evaluated using a two-stage regression model. Patient costs are adjusted for differences in payment schedules; patient age, gender, and ACG; clinic organizational variables are included as explanatory variables.

Data Collection. Patient cost data were extracted from Blue Cross claims files, and patient and physician data from their enrollee and provider data banks. Medical group practice data were obtained by a mailed survey with telephone follow-up.

Principal Findings. Capitation payment is correlated with lower patient care costs. When combined with fee-for-service with withhold provisions, this effect is smaller indicating that these two clinic payment methods are not interchangeable. Clinics with more physician compensation based on measures of resource use or based on some share of the net revenue of the clinic have lower patient care costs than those with more compensation related to productivity or based on salary. Salary compensation is strongly associated with higher costs. The use of physician profiles and clinical guidelines is associated with lower costs, but referral management systems have no such effect. The lower cost clinics are the smaller, multispecialty clinics.

Conclusions. This study indicates that payment methods at both the medical group practice and physician levels influence the cost of care. However, the methods by which that influence is manifest is not clear. Although the organizational structure of clinics and their use of managed care programs appear to play a role, this influence is less than expected.

The onset of managed care has made it increasingly difficult for physicians, hospitals and patients to completely understand the reimbursement process, specifically the contract and payment policies that drive it.

HIPAA rules and new state requirements are standardizing service definitions, payment rules and appeals with the goal of reducing contract ambiguity. However, these contract terms remain staggeringly complex and change constantly. As a result, the average healthcare organization loses up to 5 percent of its annual revenue because claims are paid at less than the contract rate.

Problem

Emory Clinic, part of Emory Healthcare, is a multispecialty Atlanta-based practice. Affiliated with the Emory University School of Medicine, the clinic employs more than 900 specialists, subspecialists and primary care physicians. Each year, the clinic submits more than one million outpatient claims worth nearly $200 million.

When a new contract management process for identifying, appealing and recovering underpaid claims resulted in major recoveries for Emory’s inpatient business in 1997, Emory Clinic management saw a significant opportunity to recover contractual underpayments for the outpatient side of the business as well. In early 2000, we began looking for a solution that would help improve overall contract performance with the goal of increasing overall revenue.

We first opted to hire outside consultants to help us audit and recover contractual underpayments, but the approach soon proved costly. Although our initial recovery efforts were successful–mostly transplant and underpaid cancer drugs–ultimately, this approach was ineffective at identifying the smaller but consistent payment variances that continued to be a drain on practice finances. We eventually agreed that we were dissatisfied with the overall return on investment we were experiencing and decided to take the job in-house in 2002.

Over the past few years, we have written many articles on potential strategies that a doctor can use to reduce income taxes, increase benefits or build retirement savings.

In that time, we have also consulted with hundreds of medical groups on how to implement such strategies for their practices. Unfortunately, these consultations too often turn out to be less than fruitful because of office politics.

Planning gridlock

Typically, while the younger members of the group are very motivated to reduce their income taxes, the older doctors are often uninterested. Either they are already so close to retirement that they don’t need extra retirement planning or they are simply set in their ways and don’t want to change anything–the old “if it ain’t broke, don’t fix it” mindset. The result: planning gridlock.

Unfortunately, for the younger physicians, the long-term costs of such gridlock are significant. They will have to work more years to reach the same retirement goals as their older partners. Gone are the “golden days” of medicine. These new times demand more creative planning.

Nonetheless, each year we meet with hundreds of motivated doctors who cannot implement the planning we recommend because the powers that be in their group won’t allow it.

Alternatives

We decided to write this article to suggest some alternatives to this dilemma:

You should consider using non-qualified retirement plans, in addition to your typical qualified pension or profit-sharing plan. That is because while tax and ERISA-qualified plans require the participation of virtually all employees, non-qualified deferred compensation plans (NQPs) can be offered to select employees.

In this context, this means that only certain physicians need participate–even if it means only one or two out of a large group.

Applying this to the common scenario described above, the younger physicians could participate in such a plan and let the older, uninterested doctors opt out.

Furthermore, when compared with qualified plans, NQPs are typically much easier and less expensive to implement.

In this way, even if a few physicians decide to implement a NQP for their practice, they could personally cover all plan expenses themselves–so their partners truly have no out-of-pocket costs. One would think that this fact alone would eliminate any gridlock.

Margins for medical group practices dropped in 2004, according to a new 2005 cost survey by the Medical Group Management Association. According to the survey, margins for internal medicine single-specialty groups decreased by 5.5 percent to $201,896, and primary care multispecialty groups not owned by hospitals saw a decrease of 3.9 percent to $217,315. Overall, multispecialty groups’ median total operating margin increased by 1.7 percent. For specialty practices, the median total medical revenue after operating costs per FFE physician grew by 5.6 percent to $387,341.

For specialty practices, the median total medical revenue after operating costs per FFE physician grew by 5.6 percent to $387,341. Among other factors, MGMA attributes the decrease in margins for single-specialty groups to the 5.7 increase in median total operating costs per physician and a 4.6 percent increase in average support-staff costs. In addition, professional liability coverage continues to increase at a consistent level for all specialties, with obstetrics and gynecology leading the pack at 5.91 percent of total medical revenue, according to the survey. Since 2003, professional liability costs per full-time physician have increased from 13 percent to 19 percent, MGMA noted.

Hospital-owned multispecialty practices seemed to do better at controlling costs, while nonhospital-owned multispecialty practices seemed to be better revenue generators, MGMA observed. Hospital-owned multispecialty practices’ total operating costs per FTE physician dropped 9.9 percent (to $283,191), while nonhospital–owned multispecialty practices saw theirs grow 3.5 percent (to $392,108). Hospital-owned multispecialty practices’ total medical revenue per FFE physician dropped 5.8 percent (to $439,672), while nonhospital-owned multispecialty practices saw theirs grow 6.3 percent (to $673,258).

Information technology can be a saving grace for specialty practices and hospitals alike. It can enable organizations to administratively achieve more with less and can put providers on the cutting clinical edge of patient safety. But when it doesn’t work as promised and must be removed, it also can create an obstacle for the future that’s hard to overcome.

Practice managers and administrative staff are more IT-adaptable than physicians, and more experienced in recovering from an IT breakdown and pushing forward with different software. But when information technology fails physicians, their reluctance to try again is understandable. It is also a critical issue to be addressed in any installation of a new solution.

The Heart Center Medical Group in Fort Wayne, Ind., has experienced tremendous growth in 10 years. We have more than doubled the number of our providers, from 20 in 1995 to a current 50 providers covering six specialties and supported by approximately 200 staff. We have eight satellite locations in addition to our main campus, and in August 2004, we moved to a new, 84,000-square-foot, custom-built facility with no medical records storage room and no paper patient charts.

This is especially newsworthy because 10 years ago, the group poured a considerable amount of money into an electronic medical record (EMR) system that failed and was deinstalled. I ought to know. As the director of information systems, I lived through it and am still employed to tell about it. But the story I want to share is the success we have had with our subsequent use of medical document imaging technology, which changed the face of our practice in exactly the way we wanted.

The Paper Was Killing Us

In 2000, five years after the failed EMR, we wrote our own code and built an intranet linked to our practice management system. We took physicians’ dictation and labs and made those available online internally. However, we were up to 30 providers who saw about 450 patients per day. We still generated too much paper, and yet we didn’t have immediate access to most of our critical patient information stored in paper files.

We had already outgrown our medical records room and were storing paper files in a classroom–which we could no longer use as a classroom. Also, we rented an outside storage facility and paid high annual fees for storage and retrieval, in addition to experiencing longer waits than we wanted for retrievals.

U.S. medical schools need to improve tuition- and fee-setting processes to help students pay their debts, the Association of American Medical Colleges said in a study.

The median indebtedness of medical school graduates has swelled from $20,000 for both private and public schools in 1984, to almost $140,000 and $100,000 for private and public schools, respectively, last year. Income is relatively flat, according to the study by an AAMC working group

To address rising tuition and debt, the AAMC advised that medical schools offer:

* Greater predictability about the student costs of a medical education.

* Ongoing financial education for students.

* More financial aid, with an emphasis on need-based scholarships, loan repayment plans, and forgiveness in exchange for military service or to underserved groups.

* Periodic self-reviews of attendance costs.

Schools should also reevaluate their funding of medical education and innovative methods to generate financial support for financial aid programs that would address current health care needs, the AAMC recommended.

The Medical Group Management Association (MGMA) traditionally provides an exhibit hall at makes others pale in comparison. This year, Oct. 3-6 in beautiful San Francisco, MGMA offers three days of exhibit hall exploration, with the chance to see an impressive array of information technology, to attendees at its annual conference. Suppliers of practice management systems, electronic medical records, scheduling, transcription and voice recognition services, wireless technology, credentialing info tech, financial and claims management systems and document management technologies will be on hand to demonstrate their products and help attendees consider what’s right for their organizations.

To help maximize your MGMA exhibit experience, Health Management Technology offers a showcase of some products you can personally test-drive at the conference. While you are there, stop by HMT Booth 1309 and say hello.

Companion Technologies develops practice management, electronic medical records and electronic data interchange software.

Companion PM is a fully integrated practice management system that works on Windows, Unix and Linux platforms. Its modular design can be scaled to meet specialty-specific requirements while accommodating changes in practice size and organization. Companion EMR is a Windows-based electronic medical records system that works on PCs, handhelds, laptops and tablets. It provides local and remote access to clinical data and automates prescriptions, labs, encounters, medical histories, patient education, and more.

Companion Technologies also offers group practice and claims management EDI systems that automate billing processes and help reduce errors, maximize reimbursement and improve cash flow.

Group visits are a fairly new approach to medical treatment. Most frequently, group visits have been used to treat a specific, chronic condition such as non-insulin-dependent diabetes. At the Sastun Center of Integrative Health Care in Mission, Kansas, we created a group medical visit program for all disease states requiring lifestyle modification.

Methods. Our group met monthly for 75 minutes. The first half of the meeting consisted of activities typical of a traditional medical visit. When patients arrived, a nurse measured vital signs and weight, including a body mass index, fat mass, and so forth. The group met around a table. After collecting signed confidentiality agreements from each patient, the physician went around the table and spent time with each patient discussing current medical problems. Unlike a typical office visit, in the group format all members listen and discuss each patient’s situation.

The second half was spent discussing a new topic. A guest speaker or another practitioner at the Sastun Center usually conducted this part of the session. Examples of discussion topics were movement for people with arthritis, yoga stretches and breathing, nutrition with a dietician, a special “dysglycemic” diet, handling holiday stress, and stress-related eating. All patients attending had 1 or more of these health problems: obesity, hypertension, type 2 diabetes, or hyperlipidemia.

Results. Five patients attended at least 4 sessions in 6 months. Other patients attended but not consistently. All members of the study and control groups were female, though this was not intentional. A majority of patients at the Sastun Center are female, so this was not surprising. The average age was 60 years (range, 52-66) for the active group and 50 years (range, 45-60) for the control group.