Top 10 Things You Need to Do as an ED Medical Director

Summary of Presentation to Medical Directors Section – October 2, 2018

#10 - Life on Display: A Picture is Worth a 1000 Words, A Video is Worth Millions (of Dollars)

Assume you are being recorded, regardless of the setting. There is a “body camera” (smart phone) in every pocket. Recent notable public and private surreptitious recordings have proven, despite laws or policies, that it will happen, and social media may be used to denigrate\blackmail those involved.

You need to address this issue for your ED to include all ED personnel. The ACEP Council and Board adopted the following resolution in October (watch for additional resources in the near future):

• Resolution 48 - Recording the Emergency Department (as amended)
• RESOLVED, That ACEP explore implications, solutions, and education/training to address (audio/video) recording in the emergency department to include surreptitious recording; and be it further
• RESOLVED, That ACEP work with other interested parties, such as the American Medical Association and American Hospital Association, to coordinate regulatory and legislative efforts to address the implications of (audio/video) recording in the emergency department.

References:

1. Elwyn, G, et al. Can patients make recordings of medical encounters? What does the law say? JAMA. 2017;318(6):513-4.
2. Reyes, Carlo, MD, JD. At Your Defense: Getting Punk'd A New Liability in EM. Emergency Medicine News: April 2018 - Vol 40 - # 4 - Page 1. https://journals.lww.com/em-news/Fulltext/2018/04000/At_Your_Defense__Getting_Punk_d_A_New_Liability_in.3.aspx
3. https://www.acep.org/patient-care/policy-statements/recording-devices-in-the-emergency-department/#sm.00018qx8kj13scf5npgep1ufqo94t
4. https://www.msn.com/en-us/news/us/emergency-room-doctor-suspended-after-being-caught-on-video-mocking-patient-suffering-anxiety-attack-are-you-dead-sir/ar-AAyPghw?ocid=spartandhp

#9 - Designated Emergency Medicine Informaticist

Do not assume your ED and physician group’s priorities are fully aligned with your hospital and its IT department. This reality is partly because of the lack of a qualified advocate to represent these interests on behalf of the ED at all levels of the organization. While most EDs have a physician assigned to manage EMS, quality, etc., few have recognized the need for a similar role for technology, to include the EMR. It should be no surprise that technology has become a huge part of emergency care, and the time has come to embrace it with appropriate resources. As with other segments of care, specific knowledge of informatics and the ability to “speak the language” will serve you well. It can also greatly assist in achieving efficiency and utility of the EMR. The “dirty little secret” of modern EMRs is that we now collect more and more information that no one ever has the time or ability to look at.

Find someone, hire someone, train someone. But get in the “informatics game”!

References:

1. Teich JM, Waeckerle JF. Emergency medical informatics. Ann Emerg Med. 1997;30(5):667–9.
2. Board Certification in Clinical Informatics: In 2013, the first certification exam was offered, and clinical informatics as a specialty was born. Fellowships are now available, and board-certified physicians in this specialty are increasingly available.

#8 - Billing\Coding\Documentation: Note Important Tasks *Compendium Available*

Review your charge master: Legacy billing “games” lead to price inflation beyond what is reasonable. With recent changes in insurance co-pays, co-insurance and deductibles, individuals are increasingly responsible for first dollar coverage. 2-3x charges are no longer necessary to maintain your ability to bill property. Ask yourself, “What would I be willing to pay?” These exorbitant “surprise bills” are not going to play well in future healthcare discussions. In fact, insurers are already using it against us.

Review insurance contracts: Most contacts have “evergreen” clauses, so that they auto review without any consideration for updates. Also, the insurance industry has changed dramatically in the last few years. Review all of your contracts at least annually and allow time to cancel\renegotiate them before the cancellation window closes.

Documentation training: Despite newer documentation systems within EMRs, most emergency physicians (EPs) do not understand how to properly document to achieve coding compliance. It’s costing you millions in downcoded charts and lost revenue opportunities!

Charting compliance audit (monthly): Training is one aspect. Monitoring compliance is even more important. For each provider, calculate how much downcoded charts, failure to document critical care, rhythm strip interpretation, etc., costs in lost billing. Then show them that number. Publish these results (blinded) to the group monthly. Behavior will change quickly.

Billing\coding audit: Do not assume your billing company is doing a great job or that your coding is accurate. Hire a professional or learn to do it yourself. You may be surprised.

Incentive-based compensation: Research has shown when a physician transitions from being an owner to employee, productivity decreases by 20%. And at least 25-50% of compensation must be at risk to alter this behavior. It is the only way to change the dynamic in the ED from “who’s going to pick up the next chart” to “give me that chart, it’s my turn to see the next patient”.

Credit card fees: If you accept credit cards (CC) for payment (and you may not even know if you do, as your billing\collections company likely handles this), you should find out just how much you are paying. You may have little choice in what you pay for “interchange fees” (or “discount rate” in AmEx speak), which is what the CC companies charge depending on the type of card used. But “merchant account fees” (there are several types, including “markup,” aka profit) can range from 0 to 1.5%, depending on the bank merchant services. Just ask and do the math. You could save $100k or more depending. BTW: Getting this information may not be easy. Bank merchant services have a vested interest in obfuscating the fees. Even if you get your monthly statement, you may not be able to figure it out on your own.

Attend ACEP’s Coding and Reimbursement Conference: This is invaluable information that will transform your ability to manage your billing operations, even if your group outsources your billing. Never assume your biller is doing it right. More information and registration at: https://www.acep.org/rc/#sm.0000w7aw77sqwex8vwb2kawl1d7vu

References:

1. *Billing Compendium: “A Pit Doc’s Guide to “Documenting for Dollars” by T Taylor, MD – Available upon request to: toddtaylormd@gmail.com
2. ACEP Reimbursement FAQs: https://www.acep.org/administration/reimbursement/reimbursement-faqs/#sm.0000w7aw77sqwex8vwb2kawl1d7vu

#7 - Hire Scribes (aka Personal Doctor Assistants) *Compendium Available*

“EDs currently using scribes report that the addition of scribes to the patient care team can help increase efficiency (patients per hour) and billing by improving documentation practices,^1,2 can increase physician satisfaction by enabling physicians to spend more time with patients and less time documenting,^3-7 and can improve patient satisfaction by increasing physician time spent engaged in bedside interactions.”^3-5   Use of Scribes: An Information Paper, ACEP, June 2011

1. Expanded scribe role boosts staff morale. ED Manag. 2009 Jul;21(7):75-7.
2. Terry C, O’Connor R, Cardella K, et al. The use of a medical scribe program to improve emergency medicine resident documentation at an academic medical. Acad Emerg Med. 2008;15(5, Suppl.1):S216.
3. Meyer H. The doctor (and his scribe) will see you now. Hosp Health Netw. 2010 Dec;84(12):41-2,44.
4. Guglielmo WJ. What a scribe can do for you. Med Econ. 2006 Jan;83(1):44-6.
5. Bukata W. Optimizing physician time. Primary Care Medical Abstracts. 2009;18:1-4.
6. Anonymous. Scribes, EMR please docs, save $600,000. ED Manag. 2009 Oct;21(10):117-8.
7. Conent RF, Topp KR. Automating workflow in the ED and beyond. Venue - The Cerner Quarterly. 2007;3(2):7-17.

References:

1. ED Scribe Compendium: - “To scribe or not to scribe” by T Taylor, MD – Includes ACEP’s Information Paper “Use of Scribes in the ED” – June 2011. Available upon request to: toddtaylormd@gmail.com
2. ACEP Quality Improvement and Patient Safety TIPS #31 “To Scribe or Not to Scribe”: Click Here
3. ACEP Scribe FAQs (January 2017): Click Here

#6 - Point of Service Revenue Capture Program (aka Turnstile ED) *Compendium Available*

Hospitals across the country are adopting ill-advised “Deferral of Care” (aka “triage out” or “screen and street”) programs in an attempt to deal with the increasing burden of the uninsured\under-insured on hospital EDs. Even the threat of multi-million-dollar EMTALA fines has not dissuaded some.

“Deferral of Care” programs show a total lack of imagination and compassion for those in need. Even worse, they are simply unnecessary.

The “Turnstile ED and Charity Care Program (TED)” concept is a responsible alterative to simple front door denial of care. Just how far “outside of the box” is this concept?

The TED program is designed to implement “patient financial responsibility management” and to reign in the entitlement state that we have allowed to develop in America’s EDs. If a hospital generally wishes to give away healthcare services with little or no expectation for payment, then those who would take advantage of such a system will gravitate to it.

The “Turnstile Emergency Department” concept involves modifications of the physical plant, changes in public perception, appropriate administrative support, employing “discharge financial planning” personnel, proper outflow at discharge and setting appropriate patient expectations from the moment of arrival.

But more than anything else, it is an attitude. Specifically, definitive arrangement for payment is expected at the conclusion of the ED visit. Patients attribute little value to services for which they are expected to pay nothing. But even those who do pay something for their healthcare seldom pay the full price.

This may seem an impossible task, in part due to EMTALA. Nevertheless, EMTALA does not prohibit demand for payment at the conclusion of services for discharged patients (EMTALA “Stable”). In reality, the poor collection experience for ED patients has more to do with poorly designed processes than it does EMTALA.

The “Turnstile ED & Charity Care Program” is perhaps the one and only solution.

References:

1. “Turnstile ED and Charity Care Program” Compendium by T Taylor, MD – Includes a full description and business plan. Available upon request to: toddtaylormd@gmail.com

#5 - Engage the Medical Staff and Administration (aka Mind Your Business)

Breakfast is the most important meal of your career: Taking time to have breakfast in the medical staff lounge with your specialty colleagues is a good first step. It is much more difficult for them to “yell at you” on the phone if they know they will face you at breakfast. This is, of course, partly a metaphor for being actively engaged with the medical staff in general and with hospital administration. As they say, “Either be at the table or on the menu.”

Be generous with your time, labor and money: Be the first to volunteer for hospital committees, special projects, and to donate to hospital-related charitable causes.

Solve problems: Don’t be a complainer. Never take an issue to the medical staff or administration for which you do not already have a ready and reasonable solution. Be your CEOs “best ally”!

Cultivate your contract: Bad things happen when you fail to tend to your “garden”. True in marriage, true in hospital politics. Never take either for granted. If you do not have general agreement on your contact renewal within six months of expiration, you may be in serious trouble. Within three months? Might want to start looking for another job! Seriously, it has happened to others with serious consequences.

See “Deal Breakers: The Summa Story”: Emergency Physicians’ Monthly - January 30, 2017. http://epmonthly.com/article/deal-breakers-summa-story/

#4A - Financial Planning - Mind Your “Own” Business, Part I: Build a Financial Fortress

Objective: Work because you want to, not because you have

How: You must begin exchanging dollars for dollars, instead of time for dollars. Time is finite. Dollars are (almost) infinite.

Why doctors are such bad investors:

1. Suffer from overconfidence, aka “I can always make more money”
2. Overly optimistic, aka find patterns and correlations where none really exist
3. Fail to start, aka allow their lifestyle to expand to meet their income
4. Fail to understand that “every dollar you save is equal to every dollar you make”

The “worst investor” (investing money in at the highest point worst time each year) will be on par with the “best investor” (investing money in at the lowest point best time each year) that starts 10 years later.

Suggestions:

1. Commit to a savings and investing plan: save (at least) 20% of your annual income every year
2. Educate yourself (&\or hire an expert): see below
3. Maximize tax savings, eg, retirement plans, education tax-free plans, etc.
4. Buy a reasonable (economical) home ASAP. Pay off mortgage ASAP. Pay cash for everything else.
5. Prepare for the worst, hope for the best.
6. Investing for Dummies by Eric Tyson, MBA – syndicated columnist

#4B - Financial Planning - Mind Your “Own” Business, Part II: Retire Well

Financial independence: a state in which an individual or household has sufficient wealth to live on without having to depend on income from some form of employment.

Do you have enough? Depends more on how long you plan to live and how healthy you are than any other factors. Standard actuarial tables may not provide accurate estimates due to advances in medicine. In your lifetime, medicine will cure cancer, heart disease, and Alzheimer's disease. For the future elderly, suicide may become the leading cause of death as people outlive their savings.

You will need sufficient funds to support your immediate family and possibly your parents and/or children if they fail to plan appropriately.

Your “retirement plan” must include some type of ongoing passive income (eg, annuities, rental property, etc.) to account for the fact you have no idea how long you may live and what additional responsibilities you may incur.

As governments continue to suffer revenue shortfalls and increasing demand by indigent elderly, new tax schemes targeting the “wealthy” may be created. Example: “personality tax” (aka personal property taxes) on temporary or moveable property such as furnishings, leisure vehicles, artwork, forms of hard currency like gold and silver, etc.). Tennessee, which does not have personal income taxes, already does this for businesses.

Estate planning: 60% of Americans lack a will or estate planning. Do not be one of them.

Several celebrities have died intestate. For example, John Wayne (Marion Robert Morrison) died at age 72 intestate. It was many years before his estate was resolved, leaving heirs without access to the funds and property laying fallow.

Avoiding probate: A will is NOT enough. You need to place assets into a revocable (or less commonly irrevocable) trust. In most states, this is the only way to avoid probate, because after your death the “trust lives on.” Turns out, the dead cannot own property (ie, you cannot take it with you). In most states, there is a fairly low limit of asset value to avoid going to court to validate\execute a “last will and testament” (called “probate”). Due to associated costs, this process can consume up to 20% of the value of an estate and take two years or more (minimum ~nine months). Funds and use of propriety may be limited by the court while this process moves forward.

Do you need professionals?

For retirement planning, most will need at least some advice from a financial planner and team (CPA, attorney, etc.), whether they end up managing your retirement funds or not. Laws are complex and vary state by state. Much of the value of these services is in tax planning, by reducing your tax liability and keeping more of what you earn.

For estate planning, virtually all high net worth individuals will need an estate attorney. Again, laws are complex, and there are many things to consider, especially if you have children. This activity may be available with your retirement planning professionals or there are certain “free” services available provided by charitable organizations. See: Thompson & Associates, https://ceplan.com/services

#3 - Get Involved in ACEP: Is Your Physician Group 100% ACEP Members?

ED directors have significant influence on other physicians in your group. If some do not belong, do you know why? Shouldn’t you know and address those reasons?

Consider making ACEP membership a “directed” benefit, ie, the group pays for membership for all physicians, and individuals do not get that money if they decline to join.

Why:

1. ED Directors’ Academy - It’s the best source to learn the tools you need to be successful whether you are a director or not. Plan for the future. https://www.acep.org/edda/
2. Organizational experience
3. Credentials for your CV
4. Many physician groups and academic programs value ACEP involvement
5. Networking contacts
6. Outlet for professional interests
7. Contribute to the success of your profession

Benefits:

1. Staff support and information
2. Legislative and regulatory advocacy
3. Representation in the House of Medicine
4. Emergency medicine research
5. Creating a positive public image for EM
6. Practice management support
7. Emergency medical services leadership
8. Opportunity to serve on ACEP committees
9. Information developed by ACEP committees and sections of membership
10. Networking and communication opportunities
11. Discounts on educational meetings and publications
12. Many, many others

How to get involved in chapter and national ACEP:

1. Show up
2. Say “yes”
3. Accept small tasks
4. Do the work
5. Challenge yourself
6. Know your goals
7. Information is key
8. Manage your time
9. Ask for help
10. Have an “understanding” partner

#2 - Be Creative

General advice

1. Don’t be defined by your circumstances – rise above and in spite of them.
2. Find solutions to the hard questions, aka, don’t take “that can’t be done” for an answer.
3. Find smart people to be around and listen to them.
4. Be willing to fail and learn.
5. Don’t be afraid to quit, if necessary. See “Upside of Quitting” below.
6. Always have a Plan B.
7. Work because you want to, not because you have to – a solution to “burn out.”

• The “Upside of Quitting” (1hr) podcast: http://freakonomics.com/podcast/the-upside-of-quitting/

Note: You may need to download the mp3 file vs streaming it.

#1 - Stay Grounded

• Stay focused, centered and present. It makes you less affected by others. You know who you are and have purpose with your life. Like being physically grounded, you are better able to keep your balance and perform actions with increased stability and confidence.
• Always keep in mind what is important. Hug your spouse, hug your children, find and maintain faith … you’re going to need them all.

Todd B. Taylor, MD, FACEP
Board Certified, Emergency Medicine, ABEM & Clinical Informatics, ABPM
Former ED Medical Director, Healthcare IT Consultant, EMTALA Compliance Consultant, Past ACEP Council Speaker