The burden placed on small businesses to comply with this new mandate will be way out of proportion to the amount of revenue that will be collected   If (and it is a mighty big IF) the estimates by the IRS and the NSBA are correct, then it will cost small businesses more in compliance costs, than the government will collect through this onerous mandate.  The IRS claims that about 85 million 1099-MISC forms are filed annually.  The NSBA claims that the number of 1099-MISC forms for the average business will increase almost five-fold (from 20 today to 95 in 2012, when the measure becomes effective.)  If both these estimates are accurate, then the total number of 1099 forms required to be filed in 2012 will be over 400 million.  If it costs $5 for each 1099-MISC form to be filed and processed (then audited, for compliance) then the drag on the economy will be greater than the revenue collected.

For the doctor in private, or group, practice the record keeping needed to comply with this new law will be very time consuming. You will need to keep track of where you purchase every item that you use within your practice.  If you buy your office supplies from several different sources to take advantage of sales or specific low priced items, you will need to record these purchases and add them up at the end of the year.  Is the total more than $600 from Office Depot, Staples, or Sam’s Club?  Then you are required to obtain their EIN and fill out and send a form 1099-MISC to them and the IRS.  Telephone charges more than $600, how about internet, cleaning service?  Get an EIN and file a 1099-MISC.  Have you bought a new computer, how about artwork for your office on E-bay, or an antique desk at a garage sale?  Be sure to get an EIN or SSN from each vendor and send them their 1099-MISC form, which you are also sending to the IRS. 

I, personally, think that this regulation will be hard to enforce without hiring an army of additional IRS agents.  But, for the doctor in private practice, this regulation gives the IRS another avenue to intimidate small businesses into tax compliance.  The IRS usually targets businesses that have significant amounts of cash transactions for audits.  The private practice doctor fits nicely into this category. (Especially, if you follow the advice in my last article) Even if you are meticulous with your tax record keeping, or have hired an accountant to handle the paperwork headaches for you (pay them over $600?  Don’t forget to file the 1099-MISC form), compliance with this regulation will be difficult.  Miss one vendor (the airline from which you bought the ticket for the out of town seminar, for example) and you are in violation of tax law. 

Another potential problem this regulation will cause is the wide spread dissemination of EIN and SSN numbers.  You are required by law to disclose your Tax Identification Number to anyone to whom you sell $600 worth of goods or services.  Some enterprising young individual will set-up a business, order $600 worth of business, obtain the vendor’s TIN (as required by law), and steal their identity. 

Fortunately, there is help on the way.  Several Representatives including Dan Lundgren(R-CA) and Jeff Terry (R-NE) have already introduced a bill to repeal this provision before it takes affect in 2012.  Sen. Mike Johanns (R – Neb) has introduced a bill on the Senate side of Congress to repeal the bill after calling it a “perverse incentive for companies to consolidate suppliers”.  Let’s hope they succeed.

Submitted by Dr. DG Comfort, CO

So, let’s look at some of the adjustments that you can make, gradually, to ensure that you can continue to provide quality care to your patients in the future.

One potential aspect of your practice that will need to be emphasized is the switch to a cash practice.  This need not be as hard as you may first envision the switch, but  in many instances it may be required, especially once the rationing of healthcare becomes necessary.  And make no mistake about it, the healthcare reform bill almost guarantees that healthcare rationing will take place in the future.

In my younger days, I spent time in New Zealand and in England and saw first hand how their National healthcare systems worked for the average citizen.  Even though there was universal healthcare coverage, many people paid cash for services that they wanted (or needed).  There was a two- tiered healthcare system in place; an official system where the government paid for healthcare, though the wait was sometimes long, and a cash system (often separate doctors) who accepted cash for quicker appointments and procedures.  This was especially true for alternative providers, whose services were not covered by the national healthcare system, or were only reimbursed with a medical doctor’s prescription.

I originally thought that only the rich would be able to afford the high tax rate to help support the National healthcare system AND pay additional cash for services that they wanted, but that was not the case.  Many working class citizens (especially those who were self-employed or farmers) could not afford to wait to be seen by the government provided doctor, so they went to cash only doctors.   These patients had to get back to work as quickly as possible in order to keep food on the table and a roof over their heads. This was especially true for those seeking treatment that was deemed non-critical by the government.

The point I’m trying to make is that even in a society where medical care is “free”, people will pay for medical care out of their own pockets, if they feel that they benefit.  Here in America, too many people have had their medical care provided by someone else (usually their employer) and have come to view medical care as a “right”, when clearly it is not. 

The challenge that doctors face is changing their patients’ attitudes back to where they are responsible for their own healthcare.  If, and when, patients take the responsibility for their own healthcare, doctors can return to treating patients as they require care, not as an insurance company (or government) decides the patient needs to be treated.  Returning to a fee for service, cash practice, will benefit both the doctor and the patient.

The patients of most alternative healthcare providers (which you have already incorporated into your practice, right?) are already accustomed to paying cash for the treatment that they receive.  Most of these patients probably have medical insurance provided for them through their employer, yet they go outside their coverage to receive the care they feel they need.  This clearly shows that people will pay cash for healthcare treatment, if they feel that their insurance doesn’t provide for their needs.  These patients will be much more amenable to paying cash for their medical treatment also.

From a purely logistical, financial, viewpoint you, as the doctor, should be able to provide better and less costly treatment if you provide the treatment and the patient pays for their treatment as they leave.  This is more efficient than having the employer hire an HR firm, who pays an insurance company, who pays an adjuster, who pays a claim sent in by a medical billing firm, (who was hired by a medical practice), after hiring someone to review the treatment notes, which were sent by a transcription service (hired by the doctor’s office), after the doctor dictated his notes justifying his treatment for the patient.

That is why the ultimate cost to the patient can be up to 50% less for the same service in a cash only practice. Of course, the patient doesn’t realize all these costs, which they are already paying for, are already built into the system.

There are still the problems of malpractice concerns and the documentation and defensive medicine which that entails; and the millions of lost jobs involved in the whole insurance-medical-legal complex, but these issues can also be resolved and will be discussed in future postings.

Submitted by Dr. DG Comfort, CO

By definition, alternative care providers offer care that is different from that which a medical doctor provides.  Often, alternative care providers have a different philosophy and treatment goal than a medical doctor has to offer.  While this may initially be viewed a threat to the medical director of the clinic, you should view this as an opportunity for expanding the scope and treatment options for your patients.  If you include alternative providers into your clinic in the proper manner, you can increase your patient base by providing medical care for their patients when it is required.

Alternative healthcare providers cover a wide range of providers with varying degrees of education and regulatory oversight.  I’m only going to cover the providers who have some sort of licensing requirements or registration requirements.

Acupuncturists are licensed or certified in all 50 states, so you can be assured that any acupuncturist that you include in your clinic will at least meet some minimum standard of proficiency.  Acupuncture treatment is designed to promote energy flow throughout the body, thus creating balance and health.  It has its place in the healing arts, and the trick is to determine if the patient will benefit from acupuncture treatment.

Chiropractors work under the theory that all health problems are caused by a lack of proper nervous system communication, and that by manipulating the spinal column they can restore normal nerve function.  Chiropractic treatment can be beneficial for patients that have minor back problems that do not require surgery.

Naturopaths treat health problems through ‘natural’ methods, such as vitamins, exercises, and herbal remedies.  They can get results with their treatment, if the problem is not severe or long standing and can treat patients with drug allergies or sensitivities.

Homeopaths use minute titrations of different substances to try to jump start the body’s response to a particular disease or to initiate a healing response.  They contend that the remedies activate the body’s respond by introducing minute quantities of the substance into the body, similar to a vaccine response.

With all these different theories and treatment options, which sometimes conflict with each other, what is the best way to include these alternative providers into your clinic?  In my experience, the best and easiest way to do it is to sublease office space to an established practitioner who already has a cliental base.  This way you do not have to pay any salary to them and you do not have the liability issues of having employees.  There are some logistics involved with this arrangement; for instance you need to make it clear to everyone (especially patients and their lawyers) that these alternative providers are operating their own businesses, and are not part of your practice.  This can be accomplished through handouts to every patient, by having separate entrances to each office, and having separate business names. 

The advantage of including several different healthcare options in one office, or at least under one roof is the potential for cross referrals.  Every patient of an alternative healthcare provider will require the services of a medical doctor at some point.  The practitioner and patient will have the incentive and convenience of referring to you for this treatment.  You may find that some of your patients would benefit from alternative treatment, also.

Then, too, some patients may be more trouble than they are worth, so if you refer them to an alternative provider within your clinic, they will still get care and they will return to you when they need medical care.  This is better for them and you, if they remain in your office setting, rather than seeing another doctor in another office, where you will probably lose them as a patient entirely.

Including alternative healthcare providers into your clinic can be a challenge, but if it done properly, it can reduce your overhead costs, provide you with a broader referral base, and provide better healthcare for the patient.  The downside is that there may be philosophical differences with these alternative providers that are too great to overcome. This will cause unneeded stress to everyone, and may cause enough friction to cause you to lose patients.

The key is choose the providers who are ethical and willing to recognize the limitations of their profession, and refer the patient to the provider best trained to meet their healthcare needs.  You can offer the best treatment options available to your patients, which will sometimes be an alternative provider.  The patient will recognize that you are a good doctor, with their best interests at heart, and they will in turn tell their friends and family how great you are.  Cross referrals within your clinic, or common office space will benefit everyone involved.

Submitted by Dr. DG Comfort, CO

You can certainly augment your marketing efforts through emails or newsletters and you can send out reminder postcards to be sure that you’re capturing annual visits. These can both be effective for increasing your daily patient count but let’s talk about a way to be more proactive without investing any money and that’s through maximizing your current patients.

We know that patients are going to no-show because of inclement weather, run late and cancel appointments. The trick is to deal with these events by doing a little damage control so that the impact isn’t catastrophic.

Start by having a clear policy in place regarding the fact that you will remain open for business during poor weather events. Allow yourself to be flexible in rescheduling these patients by opening a little earlier or staying later the next day. That sends a message to your patients that their care is of utmost importance to you.

How many times have you called a patient that was a no-show when weather wasn’t a factor and had them say, “Oh, I forgot?” The easiest way to avoid this is to pick up the phone the day before and call them to confirm their appointment. Inevitably, there will still be some no-shows but you should see a marked decrease in the number of them. If you think your patient’s are savvy enough, you can even offer them text message reminders and confirmations via email as well.

Respect the patient’s time and they will respect yours. Often, we have patients strolling in 10-15 minutes later than their scheduled time because they know they won’t be seen on time anyway. If you establish a pattern of running an efficient clinic that sees patients at their scheduled times, you’ll see a behavior change in your patients and they won’t even consider being late.

There are really only a few valid reasons why a patient should think that canceling an appointment is acceptable and among them is the death of a close family member or hospitalization of the patient. If they’re calling because of transportation issues or childcare, then they don’t really have the motivation to come in because they don’t understand the value of the appointment. Be sure that you and your staff stress the importance of patients adhering to the schedule of care that you have prescribed for them.

These simple steps can keep your waiting rooms filled with patients eager to manage their existing health problems and improve their quality of life through a partnership of mutual respect and consideration with their healthcare provider.

Yes, each of them contains relevant information about gardening, bank loan percentage rates or available candidates for hire. However, what keeps me interested is that they don’t just talk about those things. They include the latest events around town, a weekly forecast, recipes and even a joke of the day. I probably wouldn’t even remember my mortgage broker’s name 6 years later if it weren’t for this newsletter that keeps her in front of me in a non-threatening way.

E-news can do this for your practice as well. Each month you can choose a theme that you’ll focus on in your newsletter and then add some interesting “filler” information.

For example, one month you can list the cash goods and services you offer:

• Laser treatments
• Nutraceuticals
• Lotions
• Orthotics
• Contact lenses
• Cosmetic procedures

These can be supplemented by related articles about exposure to the summer sign after treatments, long term benefits of supplements and wearing contacts vs. glasses.

You can include office hours, optimal times during the day to make appointments, new insurances you’re accepting, articles of interest and even the best time to call. Be sure to post any articles you’ve personally written as well.

A unique feature of e-news is that it can be forwarded. If your reader finds your content interesting, they may forward it to their friends which in turn channels traffic to your website and consequentially, to your practice.

Visitors to your website can also sign up for web feeds. You may have seen this on sites before and wondered what it is. It’s a feed icon and by clicking it, readers can subscribe to your newsletter or website and have any updates delivered directly to their email.

There are no set rules for how an e-newsletter should be structured so once you find a template you like, it’s easy to just cut and paste your information each month for instant marketing at virtually no cost to you.

Are any of you promoting your practice to the High School sports teams in your community?

If so, what are you doing?

Please respond by posting your comments below.

The plethora of social networking options have also created new avenues for communication and marketing but you would be wise to weigh the pros and cons before diving in. Let’s focus on the largest and most well known social networking site: Facebook.

The number of members on Facebook is staggering; 400 million and growing by leaps and bounds every day. A 2009 survey by MDsearch physicians showed that 67% of physicians have Facebook profiles. Most use the site to connect personally with friends and family members but there are an increasing number of physicians who utilize Facebook to market their services via “Fan Pages”. A Fan Page allows a practice to highlight their physicians and services to people who might not otherwise have any familiarity with them and with a marketing cost of ZERO, it might be worth exploring.

Of course, there’s the traditional use of Facebook. You post pictures of your smiling family on vacation and Aunt Alice remarks on how big the children are. You check your Facebook messages and see that you have a “Friend Request” from a patient. Now what do you do?

According to Katherine Chretien in USA TODAY, you run for the hills. Well, not literally, but you do politely decline. As Ms. Chretien states, the American Medical Association hasn’t created any guidelines that mandate the use of social networking for physicians yet. However, the inference that one of your Facebook friends, Mrs. Jones, might be a patient could in itself be a violation of the Health Insurance Portability and Accountability Act (HIPAA).

This is where regularly scheduled e-news from your practice can soften the line between you and your patients while maintaining their confidentiality. A newsletter allows you to share the information both professionally and personally that you feel comfortable with sharing. There’s nothing wrong with highlighting the newest advances in medical technology along with telling your patients that you’ll be on vacation the last week of August. It not only increases their medical knowledge but it also allows them to plan their schedules accordingly.

Presenting yourself as “going green” with a “free” e-newsletter will endear you even more to your patients in this environmentally conscious, cost-cutting age. And, it’s a much more intelligent solution than risking a fine of up to $250,000 and/or prison to avoid hurting Mrs. Jones’ feelings.

Use of the internet for communication has become common practice to stay in touch with friends, business colleagues and family members. There’s no reason why it can’t be incorporated into the patient-physician relationship. The most obvious reason is the convenience factor. Often times, you are unable to return phone calls to patients during the course of a busy clinical day.

Email offers you the opportunity to answer their questions at any time, day or night, and leaves a written communication that can be easily filed within the patient’s chart for future reference. In addition, it gives you additional time to consult with colleagues or research a particular question that’s been posed. Of course, it wouldn’t be appropriate for emergencies or other urgent matters; however, there are a number of circumstances that will have you embracing the new technology.

• Providing simple test results along with your interpretation and instructions.
• Answering routine questions. i.e. What is an effective over the counter allergy pill?
• Acknowledging a prescription refill request.
• Offering links to articles or websites relevant to their health.
• Sending newsletters containing information about office hours, parking or traffic detours.

Patient confidentiality and their right to privacy should always be at the forefront of your mind with every email communication. The American Medical Association has developed guidelines for physician-patient electronic communications.

Click here to go to the guidelines.

This type of interaction enables patients to feel empowered by taking control of their healthcare and reaching out to their physician instead of searching the internet for answers. While the AMA has offered guidelines, it’s at the discretion of each individual practice to develop their own standards for implementing this method.

Some of the examples cited above are marketing tools to enhance your practice’s image and would be initiated by you. Others relate to patient care and since email communication is not covered by insurance companies, you are free to set up your own fee schedule. It’s likely that a number of patients would feel comfortable paying a nominal fee instead of co-pay for simple answers but you can modify the charges based on the feedback you receive.

Email communication isn’t meant to eliminate other forms of patient communication but instead, to enhance the patient experience and solidify the patient-physician relationship. It provides a valuable resource for patients seeking to understand their health, illness or treatment.

Let’s start by defining terms, so everyone is clear on exactly what we are talking about. 

Complimentary medicine are fields and techniques that add support to your primary practice of traditional medicine.  These fields of healthcare include:

• Osteopathic medicine – Utilizes manual joint manipulation to restore normal joint function to joints that have been injured, thus helping the healing process.
• Physical Therapy – Is utilized to reduce swelling, increase blood flow to speed healing and teaching the patient exercises and stretches to regain strength to injured tissue.
• Biofeedback therapy – A technique which uses EMG information that allows the patient to realize how they are responding to external stimuli. By teaching the patient techniques to control these responses, biofeedback attempts to minimize chronic physical and emotional conditions.
• Therapeutic massage – Is aimed at increasing blood flow to promote healing, and the removal of scar tissue and other adhesions
• Occupational therapy, Speech therapy, and other specialized therapies – All aimed at working with the patient to return them to their previous condition or to make adaptations to permanent conditions.

Alternative medicines are fields of healthcare that offer a completely different approach to that which is usually found in allopathic medicine.

• Chiropractic – is a field of healthcare that operates under the theory that the body’s entire wellbeing is controlled by the nervous system. By removing neurological interference from the spinal column through manipulation, the body will heal itself.
• Acupuncture – believes that diseases are caused by imbalances of energy (Chi or Qi) within the body.  By restoring normal energy flows throughout the body will allow the patient to return to normal health.
• Ayuvedic medicine – a system of medicine mainly practiced in India that believes that all healing comes from within.  It uses herbs, massage, yoga, and prayer to assist the body in healing.

As a new healthcare provider, you may find it much easier to establish a rapport with complimentary medical practitioners because you will have much more common ground with these practitioners.  Most complimentary medical providers are licensed as secondary providers, so they are used to working under the direction of you, the doctor, or your prescription guidelines.  Incorporating these providers into your practice or alternatively, into a group practice where the patient can obtain all of these services in one building, will give you a tremendous advantage in attracting patients to your clinic.

In my practice we cut down on every practitioner’s overhead in several ways when we combined into one large space;

• Reduced office staff – One receptionist scheduled patients for everyone, eliminating the need for each provider to have their own receptionist.
• Reduced office space requirement – By sharing common areas, such as waiting rooms, lavatories, etc. the total amount of space required to operate each practice was reduced.  We also shared rooms, by scheduling on opposite days or split day schedules.  Depending on the total patient volume, your office space requirements may be as much as 50% less in a group practice, compared to separate offices for each provider.
• Reduced support services required – Lower utilities, janitorial expenses, and maintenance requirements were all achieved by combing practices into one location.

One of the stated goals of the Healthcare Reform Bill is cut fraud and waste in the healthcare system.  You can be way ahead of the government requirements by working with complimentary healthcare providers in one office setting.  Not only will your office expenses be decreased; but by working closely with a number of complimentary providers you will able to closely monitor their treatment to ensure proper treatment for each patient, avoid duplicate treatment, and evaluate treatment being provided by each provider.  You can be proactive in controlling costs, so that when the government reduces reimbursement to healthcare providers (And you can be sure that they will), you can withstand the impact of this reduction more readily. 

Remember, we’re all in this together, and I’m pulling for you.

Submitted by Dr. DG Comfort, CO

Since the healthcare reform debate began in earnest after Barrack Obama’s election in 2008, there have an increase in the number of news articles claiming that doctors would quit in droves if the Healthcare Reform Bill was passed.  Now that the HCR Bill has passed, are doctors actually quitting, or planning to quit providing healthcare services?  The real answer is not entirely clear at this time.

Three have been many articles written on the results of a survey conducted in 2008 by the Physicians’ Foundation.  The Physicians’ Foundation mailed surveys to 270,000 primary care doctors and to 50,000 specialists.  Of the 12,000 respondents to the survey, 49% said they would consider leaving the profession, IF they had a viable alternative. 

There a couple of significant points within the responses to this survey that most of the headlines miss. 

1) The response rate to the survey was extremely low.  Less than 4% of the doctors who received the survey responded.  It is fair to conclude that if a doctor took the time to respond to the survey, that he probably would agree with the question concerning early retirement or quitting the profession.  It is human nature not to take the time to respond if your view is to keep the status quo;  i.e. not quit the profession.  I would ague that the respondents to the survey were a self selected group, who would be more apt to say that they would quit practicing medicine, and therefore heavily skewed toward those who say they would retire early.

2) Even these respondents qualify their response with the “if they had a viable alternative” phrase.  That tells me that they would switch professions if they could make as much money.  Like me, most doctors have become accustomed to a certain lifestyle, and it requires a continuing income to support that lifestyle.  Since few alternative professions can offer the same income level without extensive retraining, most doctors will continue to practice medicine, though they may wish to change professions.

While the results of this survey are disturbing; in my humble opinion, very few doctors will actually walk away from the profession.  Those who do quit the profession may be close to retirement age already, and they may just retire a few years earlier, rather than deal with the changes that are coming because of the Healthcare Reform Bill that was passed into law.  A more likely scenario will be that doctors in private practice will combine practices or work for hospitals and leave the paperwork and hassles to others.    
    
A secondary response item that I find more credible and potentially more damaging to the availability of future healthcare is that 60% of the survey respondents who said that they would discourage others from entering the medical profession.  It is much easier to avoid the medical profession altogether, than it is to walk away from it when you have over $100,000 in student loans and 8-12 years invested in your education.

If you would like to read the entire survey, it is available in booklet form in a book entitled “In their Own Words”, published by Morgan James Publishing.

Two other significant surveys of doctors were released in September 2009 on the subject of Healthcare reform; with completely opposite results being reported by the media.
     
The first one was published in the New England Journal of Medicine, and funded by The Robert Wood Johnson Foundation, stated that 73% of the doctors who responded to the survey favored some type of ‘public option’ funding of a healthcare plan. When you look at the actual results of the survey you find that of the 73% who favor some kind of ‘public option’ 63% favored a combination of public and private plans, ( Isn’t this what we currently have?); while only 10% favored a ‘public only’ option, and 27% prefer the ‘private only’ option. 

Of note, this survey had a reported response rate of 43.2%, which the much higher than the typical response to any mail survey.  It should also be pointed out that the list of doctors surveyed was obtained from the AMA and the AMA publicly endorsed the Healthcare Reform Bill.

The second survey was conducted by Investor’s Business Daily, which found that 65% of those responding opposed any plan which included a ‘proposed government expansion plan.’ The response rate to the IBD survey was less than 6%, a more typical response rate to mail surveys.

While the media has reported that these two surveys show completely opposite results, upon closer investigation they actually report similar findings.

Note:  While I was researching this posting, I came across a Fox News Health Blog where the Physicians’ Foundation survey was discussed. The Author then asked for responses to the blog.  Most of the responses were from persons within the healthcare field, though some were from patients or suppliers to healthcare personnel. Of the 145 responses, I counted less than five that were favorable toward the healthcare reform that passed earlier this year.  As the author pointed out, this is a far cry from the support for the bill from healthcare providers that the AMA and the White House have been trying to portray.

I have to wonder why the AMA has publicly supported the Healthcare reform, when so many doctors oppose it.

Submitted by Dr. DG Comfort, CO