Home Forums Discussions General Discussion Who gets the $?

So here is a question for my most reliable sounding board:

I own my own practice and hire another MD who comes in one day per week and is an independent contractor. I pay her by the hour. She pays for her own malpractice insurance but I buy everything in the office including the EHR software and all the hardware. So here is the question. The meaningful use incentive payments are per physician. Who gets the $18,000? Is it hers, mine, or do we split it? Does she get it and I deduct her portion of the cost of the EHR? Do we thumb wrestle for it?

This should be interesting.

Not completely sure
But I would think that since the incentive is related to your EHR and contingent on the Medicare billings they would go to you, assuming you are keeping the Medicare payments now.


Greg

My guess is the weasels will figure out a way to not pay either of you.

Bill,
In my opinion, unless David's prediction comes true, the money should be yours. I am not really sure how your employee could try to claim it. Do you think that the hospitals applying for MU money are planning on giving $44k bonuses to all of their employees? Of course if you decide it is appropriate to share some portion of the money in return for the employee's effort in meeting the requirements, then that is up to you.

I would ask her if she can explain MU to you, and if she can, I would give her 20%.

But seriously, given you work five "units" and she works one "unit" then the total units = six, and she works 1/6 of them.

Which means, if you did give her some, it would be 0.17 -- 1/2 the EHR. The scary part is if you look at the real fractional portion.

Now, none of that made sense.

Since she does not have the administrative codes and savvy that would be needed to run the reports needed to jump through the federal hoops, I would think this would be a moot point. T

he other issue would be that you are probably all billed to one tax id and that will be the only one that will get reimbursed.

I am guessing that it will pivot on do you bill separately for the Medicare? As Wendel stated, the TaxID (and the billing associated with that ID) will be the driver.

So who do you trust on these tricky legal issues? The cynical aviation doc (David, sometime I would like to hear more about what you do. Are there really enough plane crashes up there to make a living treating the survivors? Or do you treat healthy people, but only when they are on planes?), the even more cynical GI doc, the thoughtful and mathematically inclined pediatricians, or the tech guy? Bill, I think you need to get a lawyer. Of course, when the bill is paid, that will leave you about $2 of the 18k.....

I guess this could be kind of sticky. I think that CMS determines how many docs can apply for the MU incentive based on distinct PECOS numbers; you can't get the $ without a number. (This is different from your tax ID). The money is then paid to that provider; OR if they have assigned all of their Medicare earnings to another entity, then the money is paid there. Bill, I assume that all of your subcontractors billings are paid to your corp/LLC, etc. If not, you may have a problem. So she is eligible for the money, but you will request it (just as you bill for her E and M codes). You will then keep it and pay her by the hour (just as you keep the E and M money and pay her hourly).

Also, one thing that Jon B. regularly points out (unlike others who are less honest) is that not everyone is entitled to $18k. You can get 75% of your Medicare collections up to that amount. So unless your employee brings in more than $24k of Medicare collections a year, the amount will be less than 18k.

Jon,

Surely, you are kidding on the aviation medicine? And, I know..don't call me Surely. I feel stupid just typing this as you likely know. The first doctor I shadowed before medical school did Aviation medicine and, basically, he was credentialed to do physicals on pilots.

And, Bill, from my perspective, I would give her some amount as incentive to help, and to me, it is only fair. Otherwise, there may be hurt feelings. I remember when I worked for this other doctor, and I would see 80% of the Mainecare patients and he would get all of the Provider Incentive Program money (approximately $90,000 a year. I definitely wanted to pick up the checks after that.

Thank you all for your thoughts. I think that really helps clear up the legal issues. We see a lot of Medicare patients (not to be confused with ALOT of medicare patients-Bert) and so we will likely be eligible for the full amount. The fairness issue is the harder question. I certainly intend to share some of it with her. Maybe since I work 80% of the time and she works 20% of the time, that would be a fair split.

You have good advice above. To beat the horse a little more, the $ go to an individual "eligible provider", who has to be (individually) enrolled in the program. The 75% is of the amount that individual EP bills Medicare for the calendar year in which "meaningful use" is met. Obtuse enough?

I am probably not reading this correctly as I don't understand the entire process, but even though the "eligible provider" is the only one who receive the money, there is nothing to say that he/she can't give the money to anyone nor would there be any way to audit that.

Bert, Just the IRS

Yes, Bert, my stream of consciousness/sarcasm got the best of me once again. I give you extra points for working in the "Airplane" (the movie) reference to the aviation discussion.

I agree with Bill and the rest of you who feel that out of fairness, some portion of the incentive should be shared. The money is to compensate you for buying the software, hardware to run the network, and the labor to record the MU data as well as performing whatever reporting is involved. I would wait a little bit to see how much of this the "employee" is really doing. Personally, I think the idea that MU money is purely a function of how much Medicare business a doc sees (e.g. getting 20% of the money because she is responsible for 20% of the collections) is overly generous. But maybe I am just a cheapskate.

Again, like I said, I know very little about this or the tax code, but I don't think we are talking about getting all the money for the primary doctor and then applyng for more money for the same.

I fail to see where my getting money from the government and putting it into my bank account and then paying my employee from that money is illegal. Please show me the tax code that says doing that is illegal unless I am claiming it as an improper deduction.

It would be 17%.

Sorry I'm late getting back into the game here. Aviation medicine has to do with medical certification of pilots and related issues (like, aeromedical evacuation). You can't swing a cat in Alaska without hitting 3 pilots, so there is plenty to do. Most of us doing this are also pilots, and do it for the fun of it; we get paid a modest sum for spending half an hour talking about flying with fascinating people who are desperate to stay healthy. It is very cool. It is actually a subfield of occupational medicine, and we have a real journal "Aviation, Space, and Environmental Medicine" that publishes such pithy topics as "The Effects of +Gz Acceleration on the Circadian Cortisol Levels in Anesthetized Rats."

Aeromedical evacuation? The images that brings up are voluminous and very disturbing.

You know , i sat in on the web conference with some others on the MU stuff. And it seems liek totally tooo much work for something i don't think i will ever get paid on! I mean how much harder can they make this SH%T. what a joke. i am not interestd in doing more paper work. I would rather see more patients then waste my time.

If someone has other ideas please help. I am purely sports medicine so a lot of this stuff doesn't apply to me.

late

Ketan,

I completely agree with you. I haven't decided yet, but I agree what they want is a joke. I almost think it is a setup to get physicians to purchase EMRs by the government or even by EMR vendors.

I cannot believe how screwed up things get when the government gets involved. Left to our own devices, the physicians who understood the value of EMRs shopped for them, and people like Jon designed them. This whole MU is for the > 80% of physicians who wanted to continue with paper.

So not only are you correct about what it would mean directly to your practice, it has also wasted at least a year of development on AC and made it more bloated.

Bert, don't start sounding like me!!

I really hesitate to say what I think about this, because it makes me look like one of those "rich doctors" with too much money to consider the "little people", but I'm going to anyway.

I don't think implementing or using unhelpful parts of any tool specifically to make money is the right idea. I know, and you know, physicians who really stretch indications for procedures because of the income it will produce, not because it is good medicine. It makes me ashamed to see it. I have seen presentations on coding that stressed how to make a note that qualified as a level 4 exam when we all knew good and well that it was a middle of the road followup for a couple of everyday problems. And, I think dealing with an EMR because one hopes to get paid is similar.

I think the point of any of this was to make medicine better. I remain totally trashed out that the one thing the government could do... require common data standards so my EMR could seamlessly import records from your EMR... it failed to do. But, there is still a lot of good possible in going electronic. And, no, I do not think that being more efficient so you can spend less time with each patient, or justifying coding to a higher level, or going after government "vapormoney" is part of that good. It is part of what I think is bad in medicine.

As I have said, I sit at the end of a rather long career, considering pretty much every day if today is the day I decide to hang it up. Things were different when I was starting, building a practice, and worried about income. I realize my view is somewhat ethereal. But I really believe that the essential value of being a physician is to do something because it is the right thing to do. And, not because it makes money.

That was a privige to read. And, I completely agree about the commonality of two EMRs. And, the government should have seen this coming 20 years ago. Instead, they create HIPAA with no great way of meeting HIPAA standards when it comes to communiction.

Ironically, given I despise Logician/Centricity, my first EMR, which I would have continued had it not fallen from the clouds, was Logician Internet and then Medscape Encounter (Medscape seems to ruin everything it touches like eMedicine.com) but I digress. It was extremely useful, and it still made the best looking formatted progress note ever.

Let me add my 100% agreement to David's post and one cynical thought.

Who benefits by NOT mandating an effective means of communication across different EMR systems? EMR makers, of course, but also the big ACO's and health systems. The absence of cross-communication hands them a big tool to keep referrals and orders within the system, since everybody inside the system is likely to use the same EMR. Going outside the system will be more difficult and discouraged. If I were an ACO exec, I would be delighted with a situation where all my docs are using the same EMR system, incompatible with the system down the block.

The government is looking to encourage integrated ACO's, and the government is responsible for promulgating EMR regs and specifications. Hmm.

Michael J.

David,
Your sentiments are expressed very well, and you do not come across negatively in any way. How could one argue with ?I really believe that the essential value of being a physician is to do something because it is the right thing to do. And, not because it makes money.?? It makes me cringe when doctors express the opposing, self-serving view; sadly, we hear that all too often, usually rationalized by a variety of excuses. I also totally agree with your point about government failure to demand connectivity standards for EMR?s.

Initially I disagreed with your attitude toward MU incentives. Your post has made me reconsider my stance; now I am less sure how I feel. I know I am veering sharply into the philosophical, but consider these two scenarios:

#1: I decide that I really don?t get paid enough by CMS (Medicare) to do a colonoscopy, so each time I do one, I will take a biopsy whether the patient needs one or not. It will take me a little more time, but my payment is increased a bit, and while there is no benefit to the patient, there is really no harm done. Besides, maybe now and then the biopsy will show something that benefits the patient.

#2: CMS comes to me and says, ?We are at Point A with healthcare IT and we want to get to Point B. We know you do not think it will benefit your patients, but we think it will, and besides, there is really no harm done. We also know that it will be expensive for you to do this, and will take some extra time, so if you follow all of our rules and do it ?our way? we will pay you a bit of extra money.?

So #1 and #2 are clearly different. For starters, from a legal standpoint, #1 is illegal and #2 is not. But whereas I always thought that they were very different ethically, now after thinking about your post I am not so sure. Maybe pursuit of payments for actions that we really don?t believe is to our patients? benefit (and which by distracting us from patient care may indirectly be to their detriment) is actually wrong.

Jon, you helped articulate what I was trying to say much better.

The EMR is being heavily promoted as a gateway to make money, and much less, it seems, because it is intrinsically a good tool. OF COURSE there is nothing wrong in accepting payment for using an EMR, insofar as using the EMR is intrinsically a good thing. And, if the pathway to being paid means "first go through the blue door, then the red door", given that you are going to go through both doors anyway, then well and good. BUT, if the major incentive for installing an EMR was to get paid, when the rules suddenly change, then those that adopted because of the promise of payment feel betrayed and bitter. That sort of bitterness, I think, lies at the heart of some of the abuses you and I reference. There is a feeling of wanting revenge when some mindless third party payor unilaterally decides our services are worth next to nothing or reneges on their promises. It is much less tempting to stretch when one feels he or she is being treated fairly.

Two of my most respected professors tried to instill in me the belief that if a doctor did good by his patients, they in turn would take care of him. Mostly I have found this to be true. I think the focus should remain on the EMR as an intrinsically good thing; a tool that helps us do better medicine. Then the sense of betrayal when promises are inevitably broken might be lessened. We were all idealists when we started our careers. I think it is important to do whatever we can to retain those values.

I have been invited to multiple ACO meetings, and when the organizers go around and schmooze at the end of the meeting, it is interesting when they get to me and ask why I'm there. I explain that I'm there at the behest of a client practice, and to evaluate how quickly we can integrate with the communications back-plane that the ACO adopts. The smile generally freezes there. When I explain that the practice won't be changing EMRs, but will support the integration with the hospital's EMR as necessary. <stunned disbelief> When I point out that we will be glad to help other practices implement ACs if they choose to go that route, they generally excuse themselves.

Although unsaid, my take from several of these is that the ACO organizers are expecting everyone to become spokes (and functionaries) of the hospital and their bureaucracy; taking on their nightmare of a system.

I just heard another round of horror stories from practices who drank the koolaid and believed that the other EMR provider they left AC for was going to provide a bridge for their data still hasn't appeared almost 2 years later. I was also told by the Docs who held onto AC on my advice how glad that I was there to question the vendor more closely and warn them off.

The vendor didn't seem to appreciate my pointed & detailed questions nearly as much.

Having worked within a large system that is moving toward becoming an ACO, I can echo Indy's and Michael's posts.

Of course they want 1 system. It is the corporate philosophy. Buy 1 brand of computers even if it costs more for uniformity. Have 1 EMR because we have 1 standard even if it is not user friendly and may not do everything we want but is moving in the right direction, maybe it will get there.

Our system theoretically had a lab link to AC 2 years ago. They have yet to turn it on. They are Beta testing it, they changed vendors for their outside links and started all over, they are re Beta testing it. Their reps have no knowledge of when this will procede. Of course, if I used their EMR... (eClinicalworks)

They have a number of physicians on AC. I actually know one who was beta testing it (interesting he is since I asked about a lab link before he had AC, but that's OK, he is diligent) and was told it works well. But still, they have not released it.

I have treatened to leave their labs. Quest has a AC interface. They finally gave me a discount for cash patients I had been requesting for a long time, iff I stuck with them. Games, Games, Games.

They have stated they will have linkages for outside EMRs but with that track record, why should I expect any difference.

Just an FYI: It is always helpful to use the full name and then refer it as an acronym, e.g. Accountable Care Organization, hereafter referred to as an ACO. I say that given I had/have no idea what an ACO is/was.

I Googled it and figured it out. Here is a rather funny video:

http://commonhealth.wbur.org/2010/10/primer-what-is-an-aco-and-why-should-i-care/

It is more interesting for the fact that the voices are the same ones used in the Evo vs iPhone wars a few months back without the foul language.

All of us have already worked in ACO environment. It's the model we all trained in in residency. Wasn't that just such a perfect system (insert sarcasm here)?

Remember, you are the resident, and you call the specialty fellow on call, and beg & plead to x-ray/accept/consult/operate the patient, and you are lectured either immediately or after the consult or procedure about your inadequacies. Because the other doc has everything to gain from making you manage the problem, and spend as little effort as possible.

And once the ACO bean-counters realize that the less the group does, the more $$$ they make, all the ugly issues of cherry-picking patients, turfing sick patients elsewhere, ER tune-ups and out the door, understaffed units where doctors are expected to cover non-physician tasks, etc. are reinvented for the 21st Century of American medicine.

I don't want to practice in that setting again.