This article discusses differences between lending to the health care industry and to other, more traditional industries then looks at strategies for tapping into the significant revenue in the medical markets.

Facilitating local economic growth is a commonsense goal for banks. Key industries vary by market, but one industry must exist for any market to attract new businesses and consumers–health care. As this industry grows increasingly complex and risky, banks across the U.S. are looking for creative ways to meet its unique needs.

Most bankers think of local physician groups or hospitals in terms of core deposit relationships–and for good reason. Medical providers are typically a key source of both deposit and investment opportunity As these organizations grow however, they also have significant credit needs, both for facility expansion and for working capital. Over the years, banks have struggled with the risk/reward equation for different facets of the health care industry. The solution begins with understanding the customer.

Young and emerging medical organizations can grow quickly into large providers of various medical services. Population growth in key urban areas along with an aging population have fueled dramatic growth in just about all fields of medical service. These growing organizations need access to cash more than ever, especially during the first five years of operation. Many bankers have a real appreciation of the unique characteristics of this market because they have attempted to provide more than term note options. Some key distinguishing factors that set medical risk apart from traditional industry risk are as follows:

* Billing/claims submission to multiple guarantors.

* Claims that are subject to multiple adjustments “after” the bank has advanced the funds.

* Involvement of third-party payers, including insurance and government agencies.

* Involvement of federal agencies and the regulatory impact on the industry.

* Contractual allowances made between parties.

* Complex coding and billing procedures.

* A/R turns that often exceed 100 days as a normal course of business, whereas most other industries turn in fewer than 50 days.

* Third-party reviews of utilization and coding that could cause the provider to fail.

* The requirement for credentialing and state licensing.

* Intricacies of the aging report, such as gross-versus-net billing and “‘unbilled services.”

Implementation of interdisciplinary care models and processes has been challenging for healthcare organizations. This article describes how an interdisciplinary model of care was implemented in a progressive medical care unit.

Phase I: It Begins From the Top

The administrative leaders of a university-based medical center decided that an interdisciplinary model of care (IMOC) was needed. The leaders received the full support of all clinical and practice vice presidents, department chairs, and directors to implement an IMOC for the entire medical center. They had a clear mission–to establish an innovative model of practice that incorporates nurses, physicians, and ancillary staff into a seamless care model, resulting in improved health outcomes and at the same time providing superior, compassionate, and innovative care for all patients and their families throughout the clinical enterprise.

An Interdisciplinary Practice Council (IPC) was established and was led by an attending physician and a nursing director. The IPC included all nonclinical and clinical departments and was assigned the task of redesigning the hospital’s system for patient care delivery to enhance its effectiveness, efficiency, and safety. The team quickly developed the Interdisciplinary Professional Practice Model (the model), which was structured as 3 concentric circles. In the center was the patient and the patient’s family, and they are encircled by direct and then by indirect healthcare providers. The purposes of the model were to promote interdisciplinary collaboration, eliminate redundancies of work, improve communication links, fully use the knowledge and skills of all professions, and develop standards of practice that address the role of each healthcare professional.

The IPC identified 6 units that were interested in being pilot units. The progressive medical care unit was one of the units and it was empowered to develop a process that was based on the model. Once the process was established, it would be used as a template by other units in the hospital. The members of the IPC would actively be involved with each pilot unit as resource persons, facilitators, and encouragers.

The National Education & Development Group of Diabetes Specialist Nurses have been developing the national degree course for preparing nurses for specialist practice in diabetes care. We are pleased to report that the initial pilot site for the degree course, a collaboration between the University of Hull and University of York, is being organised.

The next pilot site for the degree will be the University of Central England in Birmingham, with other areas in the south and in Scotland following on in the next phase of the roll out of the degree programme.

Funding for the programme is currently underway with involvement of the local Work Force Development Confederations.

I have a family history of melanoma, and to make matters worse, I spent way too many of my teenage summers slathered in baby oil, lying in the sun. My skin-cancer risk is relatively high, so I get regular exams. This time, I was seeing a new dermatologist. She barreled into the room, gave me a quick once-over while she jabbered to the nurse about another patient, then left. She’d barely glanced at my skin, much less given me a chance to ask her anything. I knew that if she had missed a cancerous mole in her hurry to complete the exam, it could mean the difference between life and death–to me.

Fortunately, it didn’t, but her brusque manner had left me tongue-tied, vulnerable and ill at ease, an all too common experience for patients today. “Doctors stand over us while we’re lying on exam tables and call us by our first names while we call them by their titles,” says Jonathan H. Amsbary, Ph.D., an associate professor of health communications at the University of Alabama in Birmingham. “Plus, they’re clothed and we’re not. Of course we feel uncomfortable!”

However, from wrong diagnoses to prescriptions for medications that don’t help, studies show that poor doctor-patient communication is to blame in many cases of bad health care. So it’s vital to know what to say and when to say it during all health-related visits–including those with dentists and dietitians. Here, advice on how to better navigate your next appointment.

Before you go

* Record your medical history. “For an annual exam, take a few minutes to review your ‘health story’ from the past year,” advises Michele Curtis, M.D., M.P.H., a gynecologist in Houston. “Write down anything that’s changed, both major things like surgeries and minor things like new vitamins [or herbs] you’re taking.” Also note any health issues that have come up among your parents, grandparents and siblings, he suggests–your doctor may recommend steps to help prevent the same problems.

* Get your records. If you’ve had gynecologic surgery or a mammogram, request a copy of the procedure records from your surgeon or specialist to bring along (and keep a copy for yourself as well).

Health services researchers, health plan administrators, and health policymakers often need to identify people with specific chronic medical conditions, such as diabetes or heart failure. For example, researchers may be interested in assessing the outcomes of alternative treatments. Health plan administrators may wish to identify members for quality improvement or disease management programs. Policymakers may be interested in tracking access to or quality of care. These efforts typically rely on diagnoses listed on physician and hospital claims submitted by providers to health insurers, and pharmacy claims when available, to identify patients who have the conditions of interest.

Information about chronic conditions in administrative databases may be incomplete or inaccurate for a variety of reasons (Virnig and McBean 200l). For example, health care that is not covered or billed is not reflected in the data. Information that is unnecessary for processing payments may not be collected or recorded accurately. Even when care is sought for a chronic condition, the diagnosis might not appear on provider claims (Horner et al. 1991; Fowles et al. 1995; Fowles, Fowler, and Craft 1998). Conversely, diagnoses listed on claims may be related to testing for disease rather than confirmed disease. Despite these caveats, administrative data are used extensively by researchers and by the National Commission tot Quality Assurance, the Centers for Medicare and Medicaid Services, and managed care organizations to identify people that have specific chronic conditions (National Committee for Quality Assurance 1999; Centers for Medicare and Medicaid Services 2002a; Centers for Medicare and Medicaid Services 2002b).

During the past 20 years, the U.S. morbidity and mortality from asthma have been increasing (Mannino et al. 1998, 2002). In an effort to improve asthma care, the National Asthma Education and Prevention Program (NAEPP) published guidelines for the diagnosis and management of asthma in 1991 (NAEPP 1991). In general, physicians’ compliance with these national guidelines appears to be poor (Legorreta et al. 1998; Meng et al. 1999). However, asthma specialists (allergists and pulmonologists) appear to follow the clinical practice guidelines more closely than primary care physicians (Legorreta et al. 1998; Meng et al. 1999; Diette et al. 2001; Frieri et al. 2002). In addition, a substantial body of literature suggests that patients who are managed by asthma specialists have better outcomes than patients managed by primary care physicians (Engel et al. 1989; Mayo, Richman, and Harris 1990; Zeiger et al. 1991; Mahr and Evans 1993; Sperber et al. 1995; Storms et al. 1995; Legorreta et al. 1998; Brunner, Wunsch, and Marmot 2001). These improved outcomes included fewer asthma symptoms, improved quality of life, and fewer emergency department (ED) visits and hospitalizations (Engel et al. 1989; Mayo et al. 1990; Zeiger et al.

Long the dream of the Manhattan Beach Unified School District nursing team, a district Medical Advisory Board was launched two years ago. An expert team of medical personnel was invited to join with our district staff to guide personnel who deal with student health issues. As this pioneering group left its first meeting in June 2002, members knew they would be making a powerful contribution to the well being of our students.

How it started

Due to the many advances made in the field of medicine in recent years and the increasing populations of students with complex medical issues, school personnel felt a need to tap into additional professional resources. As general medical concerns and treatments changed, district leaders were faced with challenging decisions that affected individual students and the larger student population.

Over the years, district nurses had kept an ongoing list of medical professionals they could contact for specific student health issues. As needs of students grew, this “medical Rolodex” expanded, with the names of pediatricians, adolescent medicine experts and other specialists who were supportive in caring for our students.

In one fortuitous meeting, district nurse Judi Zimmerman had a conversation with prominent endocrinologist Dr. Kevin Kaiserman about the idea of a Medical Advisory Board that could meet regularly to guide our staff. His enthusiastic response and willingness to step in to lead the group was all the impetus that was needed for the board to be formed.

When another district nurse, Tami Simmons, had a similar conversation with her daughter’s pediatric ophthalmologist, Dr. Anne Simon, she responded with the same spirited energy.

Now that a core team of professionals was willing to come forward, some logistical planning was required. An outline stating the purpose, participating groups, time lines, focus areas and meeting dates was developed.

Located on a rural site near the Catskill Mountains in upstate New York, the Patrick H. Dollard Discovery Health Center is a new diagnostic and treatment centre providing outpatient primary and specialist medical and dental services. Owned and operated by a not-for-profit healthcare agency, the new building forms part of a larger campus that serves children and adults with profound neurological and developmental disabilities. Some 220 adults and children live on site, with another 60 adults in nearby community residences run by the centre. Around 500 people from the wider mainly agricultural community also take advantage of its services. Until recently, medical facilities were scattered across the campus, and patients could be sent on long, stressful journeys off site for routine procedures, so the new clinic provides a much-needed centralised base and focus for treatment.

Architects for the new building are Guenther 5, a New York-based practice which specialises in socially responsive architecture for healthcare and education bodies, underpinned by a strong environmental awareness. The new clinic takes its cues from local contexts–a remote pastoral setting, strong solar exposure and a windswept and snowy winter climate. Hunkered down in the landscape, the assemblage of low-rise, timber-clad volumes capped by metal monopitch roofs bear a distinct resemblance to barns or farm buildings. The architecture is modest, humanly scaled and consciously uninstitutional with the aim of transforming often negative perceptions of healthcare buildings. For many developmentally disabled adults and children, frequent medical visits are a source of fear and stress that can hinder effective diagnosis and treatment. So, for instance, the scale of the building is unimposing, natural materials are used wherever possible and all rooms have natural light and views. Though all this sounds obvious, the outcome is a thoughtful and unsentimental take on modern vernacular that in its unpretentious exterior and luminous interior has an almost Scandinavian air of sobriety and decency.

Viral Haemorrhagic Fevers is a compact and highly readable monograph written by Collin Howard, an authoritative and veteran virologist with hands-on practical experience in this field. This volume is highly satisfying on a variety of levels. Self-contained chapters deal with each of the 4 taxonomic viral families (Flaviviridae, Arenaviridae, Bunyaviridae, and Filoviridae), which make up the category of viral hemorrhagic fever agents. The properties of each virus family are presented in terms of molecular virology and replication strategy, followed by the epidemiology, clinical presentation, and treatment options. Cross-referencing to other chapters is kept to a minimum, enhancing the readability of the text. The information is reasonably current, with the exception of the current Marburg outbreak in Angola. For each virus, the author offers his candid assessment of the available treatment options. My only quibble is that I do not share his pessimism that effective vaccines will not be developed and distributed in the near future.

The author made a conscious decision to avoid encyclopedic referencing to enhance readability. On occasion, this results in bold statements that the specialist might wish had been referenced. One example is the discussion of Whitewater Arroyo virus and its probable (but contentious) role in 3 fatal cases of hemorrhagic fever from 1999 to 2000. Another is a statement that infection of endothelial cells is a critical event in the pathogenesis of Ebola virus, which, to my knowledge, has never been adequately documented.

The text is enhanced by electron micrographs of representative agents, photographs of rodent reservoirs in their native habitat, maps of geographic distributions, and schematic representations of genome organization and replication strategies. The legend to Figure 2 in the Filovirus chapter compares Marburg and Ebola viruses, but only 1 image (which I recognize to be Marburg) is displayed.

Moment by moment, a movie captures the action as a group of immune cells scrambles to counter an invasion of tuberculosis bacteria. Rushing to the site of infected lung tissue, the cells build a complex sphere of active immune cells, dead immune cells, lung tissue, and trapped bacteria. Remarkably, no lung tissue or bacterium was harmed in the making of this film. Instead, each immune cell is a computer simulation, programmed to fight virtual tuberculosis bacteria on a square of simulated lung tissue. In their computer-generated environment, these warrior cells spontaneously build a structure similar to the granulomas that medical researchers have noted in human lungs fighting tuberculosis. The simulation, created by Denise Kirschner of the University of Michigan in Ann Arbor, is an example of an emerging technique called agent-based modeling. This new tool in the world of medical research relies on computing power instead of tissues and test tubes. A growing cadre of researchers, including Kirschner, predicts that agent-based modeling will usher in a broadened understanding of complex interactions within the human body. The agents in the models are individual players–immune cells in the tuberculosis example. Each player is programmed with rules that govern its behavior. Computer-savvy researchers then set the agents free to cooperate with, compete with, or kill each other. Meanwhile, the agents must navigate the surrounding environment, whose properties can vary over space and time.

Scientists can manipulate disease progression within the models by changing the agents or their environment and then watching what happens. As opposed to traditional, biologically based in vivo or in vitro experiments, these computer trials are dubbed “in silico.” The results can suggest biological experiments to test the models’ findings and may eventually lead to new medical treatments.

Even simple rules assigned to agents can give rise to surprisingly complex behaviors. When many independent agents interact, they create phenomena–such as the granulomas–that can’t necessarily be predicted by breaking down the system into its separate components, says complex-systems specialist John Holland of the University of Michigan.