Summary of Alabama's At-Risk Provider Driven Medicaid Care Management Programs

By Richard J. Brockman and Angie Cameron

A.        Background:

Alabama recently passed into law two separate bills to develop at-risk provider-driven Medicaid care management programs. The first bill, passed in 2013, created the Regional Care Organization (RCO) system. See Alabama Code § 22-6-150 et seq. This legislation was developed upon the recommendation of the Medicaid Study Commission, which was created by the Governor who appointed members representing a range of providers, insurers, consumer advocacy groups, and state government officials. 

Under the RCO legislation, the state is to be divided into not less than five or more than eight regions. Each region is required to have a sufficient Medicaid population to support at least 2 RCOs, although there is no requirement that there be more than one RCO in a given region. By rule, the Alabama Medicaid Agency (Medicaid) established five regions. The legislation contemplates that providers in each region would convene to form and fund the RCOs. To the extent practical, the regions were designed to accommodate historical referral patterns, while having sufficient targeted Medicaid populations to support two RCOs. Currently there are eleven probationary RCOs. Three probationary RCOs are in the north region, and two probationary RCOs are in each of the other four regions. Although the legislation provides that all Medicaid beneficiaries would be assigned to a RCO, it also permits Medicaid to carve-out classes of beneficiaries. The RCO legislation further provides that long term care (LTC) services would be studied and continue to be administered under the current Medicaid system through October 1, 2016, the date the RCOs are to be operational. "Long term care services" is defined in the RCO statute as "…Medicaid funded nursing facility services, home and community based support services, and such other long-term care services as Medicaid may determine by rule…." The RCO legislation definition includes intermediate care facilities for the developmentally disabled (ICF-DDs).

The second bill, passed on May 28, 2015, created the Integrated Care Network (ICN) system. The ICN legislation authorizes a provider-driven program for the Medicaid LTC population that would function similar to the RCOs. This bill was written based on the recommendations made by the Medicaid LTC Study Task Force commissioned in the RCO legislation. Similar to the Medicaid Study Commission, the LTC Study Task Force consisted of representatives from an array of providers, consumer groups and government officials. The task force received reports from various of its members, as well as persons and groups outside its membership. 

The ICN legislation contemplates that providers would convene to form and fund the ICNs and that Medicaid would assign LTC beneficiaries to the ICNs. In addition to care managing Medicaid beneficiaries and their benefits, the legislation permits ICNs to coordinate with other provider programs. The ICN program is to be operational no later than October 1, 2018.  This bill further provides that until the ICN program is operational, LTC services would continue to be administered by Medicaid under its current program.

The RCO and ICN entities will each receive an actuarially determined monthly per member-per month (PMPM) payment from Medicaid and in return (i) case manage assigned Medicaid beneficiaries and (ii) process claims and pay providers for Medicaid covered goods and services provided to its assigned Medicaid beneficiaries. RCOs and ICNs are deemed to be "at-risk" entities because, in accepting the actuarially determined PMPM payment, each (i) assumes all responsibility for care managing, claims processing, and paying Medicaid covered claims for its assigned Medicaid beneficiaries, and (ii) must make up any short-falls. 

Medicaid has applied to the Centers for Medicare and Medicaid Services, Department of Health and Human Services (CMS) for a section 1115 waiver for the RCOs. (States may apply to CMS for waivers from certain federal Medicaid state plan requirements. These waiver applications refer to specific sections of the federal Medicaid statute). It is contemplated that the ICN program will either be added to that section 1115 waiver application or there will be a separate section 1115 waiver filing, as well as a filing to apply for a section 1915 waiver for the home care portions of the ICN program.

B.        Comparison of the Features in the RCO and ICN Legislation:

1. Formation: Collaborators (e.g., providers, suppliers, and investors) can apply to form a RCO or ICN, and based on criteria, Medicaid can confer RCO or ICN status on qualified applicants.

2. Boards: Each RCO and each ICN will have a 20-member board consisting of (i) 12-members representing at-risk members, and (ii) 8 members who are not-at risk. The at-risk members either put up capital or agree to provide Medicaid services even if the RCO or ICN has no funds to pay for services. Each RCO board must meet certain prescribed composition requirements for its non-at-risk membership. Other than the number of at risk and non-at-risk representatives, the ICN legislation is silent on composition. For either a RCO or ICN, a majority of a board's at-risk members cannot be from a single provider, unless that RCO or ICN has only one at risk provider. Each RCO and each ICN also must have a citizens' advisory committee. There are differences in the citizens' advisory committee compositions. For instance, an ICN must have representatives from Disabilities Leadership Coalition of Alabama or Alabama ARISE, the Alabama Chapter of AARP, Alabama Disability Advocacy Program, the Disability Rights and Resources, and ARC of Alabama. The RCOs must have representatives from Disabilities Leadership Coalition of Alabama or Alabama ARISE. Each must have representation of Medicaid beneficiaries. All boards must meet the population diversity make-up of the region served. There are prescribed minimum frequencies the boards must meet, and Medicaid reserves approval over all board activities.

3. Anti-trust and Insurance Exemptions: Each statute (i) provides for Medicaid "state action" supervision over the collaboration of conveners seeking to form a RCO or an ICN, (ii) gives express exemptions from state anti-trust provisions, and (iii) grants an exemption from state department of insurance requirements and supervision.

4. Medicaid Supervision Over Governance: Medicaid has control over approving RCO and ICN charters, bylaws, and board members (including filling board vacancies left unfilled for more than three months).

5. Quality Assurance:  Medicaid appointed Quality Assurance (QA) committees will review patient outcomes, costs, and operational results of each ICN and RCO. Negative QA findings can lead to discipline or termination of a non-compliant RCO or ICN. The composition of the QA committee for RCOs requires that at least 60 percent of the members be physicians serving RCO beneficiaries. The ICN statute leaves the ICN QA committee's composition to rule making.

6. Appeals: Each statute has a prescribed administrative appeals process for providers and beneficiaries, and RCOs and ICNs are also afforded a process to appeal adverse Medicaid decisions.

7. Per Member-Per Month Payments: Based on actuarially derived calculations for the population to be served, Medicaid will pay each RCO and each ICN a separately calculated PMPM payment, and each RCO and ICN is responsible for (i) case managing its members, (ii) processing and paying providers and suppliers for Medicaid goods and services provided to its respective members, and (iii) making-up any shortfalls.

8. Scope of Services: Each RCO and ICN is responsible to pay for all covered Medicaid services provided to each beneficiary assigned to it. For example, in the case of a beneficiary who is a nursing facility resident, the ICN, in addition to paying for that beneficiary's Medicaid covered nursing facility care, is responsible for Medicaid covered physician, hospital, pharmacy, or other covered Medicaid services provided to that beneficiary. A RCO likewise is responsible for all Medicaid services required for its beneficiaries regardless of provider or setting.

9. Any Willing Provider and Reimbursement: Each RCO and ICN must contract with any willing Medicaid qualified provider and reimbursement to providers cannot be less than the current Medicaid payment regime. Medicaid sets minimum payment levels.

10. Operational Capabilities:   Each RCO and ICN must demonstrate the ability to (i) attract a provider network, (ii) case manage beneficiaries, and (iii) process claims.  These functions may be subcontracted.

11. Beneficiary Assignment. Unless a beneficiary is in a carved-out class, each Medicaid beneficiary must be assigned to either a RCO or ICN, but no beneficiary can be assigned to both a RCO and an ICN.

C.        Summary of Differences in RCO & ICN Legislation:

1. Application and Selection Process:

            a) RCO applicants must first pass through a phased probational period and be fully operational by October 1, 2016. Under this phased system of evaluation, to receive full status, a RCO applicant must: (i) by October 1, 2014, have organized and established an approved board and received probational status; (ii) by April 1, 2015, have developed a provider network; (iii) by October 1, 2015, show solvency is met; and (iv) by October 1, 2016, be certified as a fully operational RCO. To be "fully operational," the RCO must meet the first three timeline criteria, as well as demonstrate the ability to case manage beneficiaries, and process, manage, and pay claims.

            b) ICN applicants will be selected through a competitive bid or procurement process as follows:  (i) by April 1, 2017, Medicaid must establish the selection criteria and process; (ii) by April 1, 2018, applications to be an ICN must be submitted; and (iii) by October 1, 2018, each selected ICN must be fully operational by showing it (A) has organized and established an approved board, (B) has developed a provider network, (C) meets its solvency requirements, and (D) possesses the ability to case manage beneficiaries, and process, manage, and pay claims.

Each RCO and ICN also should have a functioning citizens' advisory committee meeting its respective legislative composition directive.

2. Service Area and Population to be Served:

a) Each RCO serves certain assigned Medicaid beneficiaries living within a defined region of the state. Medicaid determines which classes of beneficiaries the RCO will serve, although the LTC population is reserved by statute for the ICNs.

            b) The ICN legislation authorizes one or more ICNs. There are no defined boundaries for ICNs, but Medicaid could by regulation define areas to be served by ICNs, or designate that the ICNs be statewide. The number of ICNs will be determined by Medicaid. ICNs will serve those Medicaid beneficiaries receiving services by either a nursing facility or home and community based waiver program.

3. Capital and Reserve requirements:

            a) Each RCO must have $2.5 million in capital and cash reserves equal to 25 percent of one month's claims. A RCO can meet its reserve requirements by posting a surety bond. No assets of the RCO can be pledged to secure the bond.

            b) Each ICN must meet solvency requirements set by Medicaid through rule making. An ICN can post an irrevocable letter of credit (issued by a state or federally chartered bank with at least $4 billion in assets) to secure its reserve requirements. No assets of the ICN can be used to secure the irrevocable letter of credit.

4.         Alternatives:

            a) If no RCO manifests in any designated region, then Medicaid may, but is not required to, contract with an alternative care provider, which could be a commercial managed care company or some other type of Medicaid care management system.

            b) If no ICN manifests, Medicaid must continue administering the LTC program under its current system.

5. Beneficiary Options.

            a) RCO designated beneficiaries are to be passively enrolled by Medicaid into the RCOs. If there is more than one RCO in a region, the beneficiary may choose between the RCOs. If the beneficiary does not choose a RCO, Medicaid will assign the person to a RCO. Medicaid may limit the circumstances under which a Medicaid beneficiary may change care organizations. It does not appear as though a beneficiary may opt out of the RCO.

            b) ICN designated beneficiaries are to be passively enrolled by Medicaid into the ICN, but if Medicaid determines there should be only a single statewide ICN, the legislation suggests that Medicaid could provide beneficiary choice by permitting beneficiaries to opt out and be administered by Medicaid.

6. Program integration with other health plans and payors:

            a) RCO legislation provides that the RCOs serve only Medicaid beneficiaries, and is silent on program integration.

            b) ICN legislation provides that in addition to serving Medicaid beneficiaries, the ICN can coordinate care through an affiliation with other programs. It further describes the class of Medicaid beneficiaries to be assigned to an ICN as those eligible for nursing facility services or home and community based waiver programs, and those Medicaid beneficiaries who are also eligible for Medicare.

7. Contracts:   

            a) Initial RCO contracts are for three years, with options for two one-year extensions. If the RCO performs, Medicaid may enter into additional multi-year contracts.

            b) Initial ICN contracts are for two years, with options for three one-year extensions.  If the ICN performs, Medicaid may enter into additional multi-year contracts.

A contract for either a RCO or ICN may be terminated by Medicaid for non-performance, subject to administrative appeals.

D. Conclusion:

Under the RCO and ICN programs, Alabama providers (with consumer input through non-at-risk board membership) are given the unique opportunity to develop and apply innovative and creative methods for case managing assigned Medicaid beneficiaries through collaborating provider networks. Establishing the RCOs and ICNs will require significant investment by the provider community. While these are difficult undertakings, Alabama's Governor and Legislature have deemed that this course has the potential to not only create tangible Medicaid program savings by requiring the RCOs and ICNs to promote care collaboration among providers, thereby bending the growth curve, but also, through this system of care collaboration, develop better access to needed medical treatment and better quality of care and life for its citizens who are Medicaid beneficiaries. It is anticipated that these provider collaborating networks will reach into other payor classes, such as Medicare, to innovate better care coordination throughout the care continuum and permitting these benefits to have wider application.

Richard Brockman is Counsel with Burr & Forman LLP. He is also the current President of the Alabama Nursing Home Association.  Richard served on the Governor's Medicaid Study Commission during the development of the RCO legislation and worked with the Medicaid LTC Task Force in the development of the ICN legislation.

Angie Cameron is a Partner with Burr & Forman LLP practicing in the firm's healthcare group.

Critical Care Medicine

By: Dr. Leslie Hayes


Every year, hundreds of children are admitted to critical care units at Children’s of Alabama. These patients come from within Alabama and from every surrounding state. They come because we offer them a broad variety of life-sustaining care. We see trauma victims and brain injury patients. There are post-operative surgical patients who need close monitoring. And there are premature babies. In fact, if you name a severe, life-threatening illness or condition, we’ve most likely seen it.


Dr. Sam Tilden started critical care services at Children’s in the late 1980s, and now we have one of the busiest critical care systems in the nation for children. We spend a tremendous amount of time and resources ensuring that our critically ill and injured patients are cared for by the best, fully trained health professionals using the most advanced medical technology. We have nine critical care faculty members and another six faculty members just for the cardiac ICU. We train six critical care fellows at a time.


The Children’s Pediatric Intensive Care Unit (PICU), where I spend much of my time, has 22 beds and is located on the seventh floor of the Quarterback Tower in the Benjamin Russell Hospital for Children, and has about 1,400 admissions a year. Nearly all of our critical care patients are in Benjamin Russell Hospital for Children, but the neonatology service additionally has patients at UAB’s Regional Neonatal Intensive Care Unit connected to OB/GYN services at UAB. Children’s has its own 48-bed neonatal intensive care unit, along with a 20-room cardiac intensive care unit and also a burn center that cares more than 170 patients a year. In addition, Children’s operates a 26-bed special care unit, which is a step-down unit for our ICUs.


The PICU handles the greatest variety of patients. Adult intensive care units (ICUs) tend to be subdivided into more specialized units. Our PICU takes patients needing high-level monitoring, intense observation, special procedures and numerous interventions. Patients range in age from birth through young adulthood. Nurses care for one or two patients at a time, depending upon the severity of illness. We welcome and encourage parents to stay with their children.


Education and training are constant and intense. We train fellows, pediatric medical students, nurses and other medical staff. We are dedicated to our trainees. Our aim is to develop leaders and top-notch researchers.


We are strong advocates for continuous quality improvement. We are always looking for ways to improve care. We exchange research with other pediatric hospitals to ensure that we are operating on par with our peers, and staying abreast of new techniques.


Staying on the cutting edge of medical technology is important. It makes caring for patients easier and more effective. For example, we are now using very high quality ultrasound devices while placing central lines in children. That new technology has significantly improved the safety and quality of central line placement. We also have new video devices that we use while performing intubations to place a patient on mechanical ventilation. This device helps us perform that procedure more safely while also allowing trainees to observe the process.


We try to minimize the risks of hospitalization for children by reducing the amount of time they spend in the ICU, and we are good at that. When compared to our peer ICUs across the country, we have shorter lengths of stay. Providing the most effective care in the shortest amount of time helps return children quickly to their optimal state of health.


Unfortunately, when working with critically ill or injured patients, outcomes aren’t always what we’d like. Sometimes all we can do is deliver the safest and highest quality care in the most efficient way. We have to recognize that children sometimes have an illness that we are unable to cure. At those times we have to work in a family-centered way to understand goals of care for that child and work with the family to do all that is possible.


Critical care medicine is extremely difficult work, but it is also personally rewarding.



Dr. Leslie Hayes is a certified pediatric critical care physician at Children’s of Alabama and an associate professor of pediatrics in the Division of Pediatric Critical Care at the University of Alabama at Birmingham (UAB)) where she trains medical students and doctors in pediatric critical care.

Practice Administrators: Taking a Knife to a Gun Battle

By: William Sester, RN, MSN, CPC


In the most recent publishing of the Birmingham Medical News, there was an article entitled: Where Have All the Practice Administrators Gone?  

An interesting follow up question would be: Why are all the practice administrators leaving?


I am a former private physician practice administrator. After working in the trenches for 14 years, four months ago I was offered a unique opportunity to work for TekLinks, my former IT support vendor, as their Director of Healthcare Solutions. By hiring me TekLinks demonstrated a commitment to the healthcare market, which was strengthened even further by their recent acquisition of Claris Networks, a Tennessee-based IT company with a significant healthcare customer base. Now I serve as a “focus group of one” inside TekLinks, supporting my fellow practice administrators internally and serving as a value-added resource to our healthcare clients externally. My position allows me to use my extensive healthcare experience to bridge a knowledge gap, to explain the inner workings of a private physician practice, and expose my new colleagues to a business model that seems almost ridiculously unfair to them in the wake of the Affordable Care Act.


No one would ever bring a knife to a gun battle. Yet, that is what most physician practice administrators are doing each and every day. Managing a private physician medical group is unlike any other business model. It is not a fair fight. Let me explain using just one example – expenses.


Expenses go up every year in a medical practice. Employee salaries, health insurance premiums, malpractice coverage, specialty drugs necessary for office based procedures, and sometimes rent … just to name a few. In most business models, as costs rise, managers must manage their expenses better, increase business efficiencies, get creative with their expenditures, and when all else fails, they at least have the option to pass those necessary cost increases on to the consumer. In private physician practice management, that consumer would be the health insurance companies and the patients.


Let’s imagine you pass a fruit stand every day on your way into work. This farmer has some of the best local peaches around. He sells them for $3.00/basket and they are delicious. What if a bad run of dry weather causes him to use more water for his peach trees, fertilizer or pesticide costs go up, or perhaps gasoline hits $4.50/gallon? This local farmer is in a pinch and has to make the decision to cut his expenses where he can and become more efficient in what he does to offset his rising costs. But after exhausting his options, he has no choice but to increase the price of his basket of peaches to $3.50/basket to offset his rising costs. Now, as you drive into work and make your weekly stop to pick up your fresh peaches, you have a consumer decision to make. Are you willing to pay $3.50 for this same basket of peaches you just paid $3.00 for last week? Some patrons will, and some will not. Some may pay it this time but come back every other week, instead of every week as they used to. That is a risk the local farmer was willing to take because he HAD to find a way to maintain his business’s profitability in the midst of rising costs. And the only way to do that was to pass the necessary additional costs on to the consumer.


Private physician practice management is much different. Employee health benefits are a top ten annual expenditure. Every year health insurance companies meet with the practice administrator to discuss the annual renewal of the practice’s health insurance benefit. Every administrator hates this time of the year. Why? They know what is coming - another increase. Health insurance premiums in Alabama have increased over 100% in the last 15 years. That means if it cost $250/month to provide an employee health insurance 15 years ago, it would now cost $500/month for the same health plan, assuming you could purchase the same health plan (you cannot). Most physician practices did what they were forced to do: they evaluated the plan offerings, analyzed several competitors’ health insurance plans, and ultimately selected a plan that had less coverage for its employees. Typically, the lesser coverage plan came at the same or even at a slightly higher cost. In short, the practice was paying over twice the premium for less health insurance benefits. Did the employees feel the difference in the change to those health benefits? Of course they did. They were most likely asked to start paying a portion of their less-rich health benefit, something that was previously a benefit provided 100% by the physician practice. So now a loyal physician’s nurse that has been with the company for fifteen years brings less money home to her family because her company needed her to start paying part of her health insurance benefit.


In the above example, a top ten annual practice expenditure is analyzed and demonstrates the real world impact of decisions practice administrators have to make each and every day. In a ten-doctor practice, it is not uncommon to see health and dental benefits cost nearly $40,000/month. Yes - per month.


What is not mentioned in the above scenario is the increased health benefit cost making its way back to the consumer. Why? It cannot. Most private physician practices have a contract in place that binds them to a particular fee schedule set by the insurance company. Medicare’s fee schedule changes every year. A practice’s only decision to make each year for Medicare is: will we continue to see Medicare patients at this year’s new payment rates? For commercial insurance carriers in Alabama, the rates in their entirety typically do not change year after year. Certain fees will be adjusted annually as the payer sees fit to do so, based on a number of metrics they analyze. Most healthcare consultants would jump in right here and tell you to negotiate your payment rates with your payers. In Alabama, depending on the type of physician practice you manage, it is not uncommon to have the extreme majority of your contracted payers be two insurance companies, both of which do not allow you to negotiate your contracts. So each year there is a decision to make: will we continue to see these two types of payers? The answer is almost always “yes” because you cannot afford not to.


So how do you operate a privately owned small business where major expenses rise every year, you cannot push the rising costs onto the consumer, and the majority of the fixed fee schedules you operate from are non-negotiable, rarely go up, and seem to always go down? You get creative. You find new ways to cut costs each year while remaining competitive. Every business competes for exceptional employees, so you have to make sure the benefit package you are offering your employees is competitive in nature. Aside from any remaining savings you can find, you must implement and maintain effective revenue cycle management processes to collect all monies both the payers AND the patients owe your practice. Try to find more efficiencies to increase the amount of work your physicians and staff do each and every day, and determine if you can add any new service line to your practice that stays within the scope of your group/specialty.


Shareholder physicians (the business owners) no longer have an expectation of making more money year after year. They’re hoping to make the same amount of money they did last year and accept the fact that they will most likely work harder to earn the same paycheck. What employee stays with an organization that demands more work out of them each and every year, but tells the employee you may make less this year than you did last year as a result of your extra efforts? As this cycle continues, the next article written will probably be entitled, “Where Have All the Private Physician Practices Gone?” And perhaps another shortly afterward will read, “Where Have All the Experienced Physicians Gone?”


In fairness to the insurance companies, they have started sweetening the pot for some physician specialties. Everyone is in pursuit of value-based care. This is simply the highest quality of care at the lowest possible price. Value = quality divided by total cost. As insurance companies begin to seek the best answer to value-based medicine, they are finding ways to incentivize the better performing physicians and physician groups. This is a positive step in the right direction, but brings on a whole host of private physician practice administrator nightmares as these results are data driven, and most practices do not have data analysts on staff.


Until the private physician practice administrator has the option to push their rising expenditures on to the consumer, I think you will continue to see an increase in the departure of the seasoned administrators, private physician practices, and veteran physicians. They will retire or begin to pursue other business opportunities that operate in a fair business model. Who knows, they may start selling peaches curbside.



William Sester, RN, MSN, CPC
Director of Healthcare Solutions wsester@teklinks.com  
d:205.443.6997 c:205.994.5561
www.teklinks.com/health-services-group 

Cryosurgery

By: Dr. Lee Hammontree, Urology Centers of Alabama


Cryosurgery is the use of extreme cold produced by argon gas to destroy abnormal tissue. This technique is used to treat external growths on the skin. External growths can include benign and malignant skin conditions and warts. Gas is circulated through a hollow instrument called a cryoproge to target the growth filling the cells with crystals comprised of ice to destroy the cells by ripping them apart.


Cryosurgery can also be used on tumors inside the body. When using cryosurgery for internal tumors, an ultrasound or MRI is used to guide the cryoprobe and monitor the freezing process to minimize the damage done to healthy tissue. Often more than one probes will be used to deliver the gas to different parts of the tumor.


During these procedures, an ultrasound probe, which goes through a laparoscopic port is used for intra-operative real-time imaging of the mass and monitoring of the freezing process. It is usually an transabdominal laparoscopic approach and the size limit has been tumors 4cm in size or less. When the tumor is posterior, the procedure may be done in an extra peritoneal laparoscopic approach which leads to less intra-abdominal morbidity. A biopsy with a true cut spring loaded biopsy needle is performed immediately preceding placement of the cryoprobe so that there is pathological documentation of the mass. The cryoprobe is capable of production of an “ice ball” formation with temperatures reaching less than negative 40 degrees C. Depending on the size of the mass and its configuration, either multiple or single probe use may be needed. It is recognized that tumors 4cm or less in size constitute appropriate tumors to be considered for laparoscopic cryoablation of renal tumors. In some patients, it may be necessary to use a hand assisted laparoscopic approach or even an open approach for cryoablation procedures. There may be times that a CT guided percutaneous approach would be indicated.


Laparoscopic cryoablation for renal masses 4cm or less is an effective treatment for small renal masses. We are less likely to recommend this treatment in tumors approaching 4cm and would recommend robotic partial nephrectomy for those tumors. Complexity scoring of the tumor is useful and increased complexity correlates to complication rates. Cancer outcomes are excellent and the local recurrence rate is very low in tumors under 3.5cm.

“It’s Time to ‘Up Periscope’ Before you Breach the Surface”

By: Susan Pretnar, President KeySys Health, LLC


Many healthcare practices think data security is purely an IT issue, hoisted on them because they have been FORCED to use electronic technologies in their business, especially an EMR. “We wouldn’t be exposed if we were still on paper” they groan. In truth, it doesn’t take any time to reflect on plenty of incidents around paper charts and negligent employee actions. Until very recently, network breaches were rare in comparison to how PHI has been compromised by trusted employees and vendors. But, times do change, and rapidly. Hackers have discovered a very porous new frontier: healthcare.


Now that your doctors have the latest smartphones and tablets, how are you dealing with the new reality that your “perimeter” has changed? Where is your patient’s PHI coming from and going? If you don’t really know, it is time for a deep dive until you can come up safely.


The only way to get a grip on your PHI is to do a thorough risk assessment. Scratching the surface with a checklist to ‘get er done’ as they say, will not really do that. In the past, you might never have known until you were sued that an employee copied a bundle of your paper charts to get money to pay off a loan. Who can be sure of who has touched a paper record? If you are not critically looking at your network traffic, your devices and software applications, you are wading into the sea of electronic technologies without acknowledging what is right at the surface that could destroy your practice or devastate your patients. In truth, with the proper monitoring, you might be the first to know, instead of the last, that an employee is out of bounds, because properly configured electronic technologies often leave a trail.


Compromised PHI is big business. The value of a single medical record is estimated to be more than $300 on the Black Market. At a minimum, data loss prevention, the buzzword around information security, requires that you know where your data is coming from, where it is going, how it gets from point A to point B, how it is stored and who has access to it. It takes some time and commitment to document this inventory. It also takes time and commitment (especially financial) to select and maintain the right technologies that support your operations and security efforts.


Don’t underestimate the value of training, so often overlooked as just another interruption to a busy day. If you handed your employees a manual on their first day of hire that includes your expectations for them to protect the privacy of your patient’s information, but you have never reinforced the procedures that might actually assure that will happen, you are indeed breaching the surface of the vast electronic sea, without a look at what is sitting right on top of the water.

Fabry disease

By: Dr. Melanie Sivley, O.D., F.A.A.O


Many serious diseases, such as diabetes, high blood pressure, heart disease and thyroid disease, commonly affect the eyes. Evidence of these diseases can be recognized during an eye exam because neurologic and vascular structures of the eye are visible to an optometrist or ophthalmologist. Genetic diseases are more rare, but many can be identified during an eye exam, as well.


Fabry disease is a potentially fatal genetic disorder that can be first detected during a routine eye examination. It is the result of a gene defect that causes particular fat molecules to build up in cells throughout the body. Fabry disease is believed to affect as many as 1 in 3,000 males and at least as many females. The effects are usually seen earlier and are more severe in males. There is no cure for Fabry disease, but treatment to manage the condition is available.


Early symptoms of Fabry disease may begin in childhood and include pain in the hands and feet, reduced ability to sweat, heat intolerance, unexplained fevers, red bumps on the skin, and gastrointestinal problems. Fabry disease also affects the kidneys, heart, brain, and blood vessels. Without treatment, premature death may result from kidney failure, heart attack and stroke at a relatively young age. Symptoms may not be obvious until adulthood, and some Fabry patients may never develop symptoms, unknowingly passing the disease from generation to generation. It is therefore important to catch the condition before irreversible organ damage occurs.


In most cases, the alert eye care practitioner can see a whorl-like pattern within the clear cornea of the eye. This pattern is highly suggestive of Fabry disease and is present in almost all individuals, symptomatic or not, who have the condition. Other eye effects of Fabry disease include cataracts, distortion of the blood vessels on the inside and outside of the eyeball, dry eyes, and optic nerve problems. These eye findings also accompany other conditions, so Fabry disease can go unrecognized until the disease is advanced.


Early detection is the key to early intervention and treatment with enzyme replacement therapy, which clears the build-up of fat molecules from many body tissues and allows Fabry patients to live a more normal life.


Much of the pain and suffering of Fabry disease can be avoided if an eye care practitioner recognizes the condition and makes the appropriate referral. Entire families can be alerted to a disease of which they were previously unaware. This knowledge then allows the patient and affected family members to be appropriately treated and genetic counseling made available for future generations.



Dr. Melanie Sivley, O.D., F.A.A.O., is Director of the Fabry Eye Service at the UAB School of Optometry and conducts research on the ophthalmic manifestations of Fabry disease.

Growing Pains In The Practice?

By Lisa Kianoff, CPA.CITP, CGMA


First there were just 2 doctors and business wasn’t too complicated. Soon the practice grew to 4 doctors and then an opportunity to add in a specialist. Well, now there are 9 physicians, 3 nurse practioners, MRI, ultrasound equipment and talk of opening a second location. Things have become complicated. What has not changed in this healthcare practice that now employs 36? Still running the business and paying bills with the $299 accounting system bought at the office supply store years ago. Sound familiar?


As your practice grows so too do your needs. The question is: When do your needs exceed the capabilities of - or break - your systems? From 3 decades of supporting healthcare organizations, here is what we see as the Top 5 triggers that signal business pains are impacting the health of a practice.

1. Hard to Get Information: You find yourself anxious for information you’ve been told is too hard to get. You need specifics to understand what’s happening financially from a business view. You’d know better how to react if you could track such metrics as revenue or expenses per patient visit, revenue per employee, or monthly labor costs of each professional by category.

2. Too Many Moving Parts: You will never be able to see a complete view of your healthcare practice because your Patient Billing system doesn’t talk to your Accounting system. Your staff still manually enters revenue, accounts receivable or payroll data from other systems. Patient refunds impact both patient billing and corporate accounting so managing patient payables is time consuming and complicated. You know that distributing expenses to doctors and/or practice departments would provide more meaningful financial information; but you have no easy way to allocate these expenses to make it happen. Truth be told, your entry level system simply can’t handle this critical piece: Using both fixed and variable allocations to automatically assign expenses for rent, salaries, overhead and more.

3. Financials May Not Tell the Whole Story: Sure, you get Income Statements and Balance Sheets, but in a format a decade behind the times. Your practice is now multi-faceted but your financials don’t reflect that: Where are the comparisons of locations and labor costs, specialty metrics across all locations, or Revenue per FTE (Full Time Equivalent)? Where are the physician centric reports? Oh, for some dashboards showing current data, metrics and views that help turn your financials into a true management tool. That entry level accounting software is too basic to let you look beyond the General Ledger, with limited or no tools to create reports or analyze data from subsidiary modules to offer metrics related to vendor analysis, inventory costs or labor detail.

4. Labor Costs Need Oversight: The biggest expense in healthcare – like any business – is payroll. How well do you understand that expense? Where are the detailed views of payroll expenses in relation to revenue, specialty, department or FTE? How many systems, mostly manual, do you use to keep up with certifications, trainings, benefits, reviews, grievances, ACA reporting and more. And the big one: How comfortable are you that you are correctly keeping up with staff splitting time and taxes across locations, departments or profit centers? So much to manage and monitor. Fact is, an integrated business management and accounting system, with tools for managing payroll and HR, is flexible enough to meet those needs. And bringing payroll in-house means you have all that needed labor information at your fingertips and in your control.

5. Lenders Aren’t Impressed: You are ready to buy some vital new equipment or to expand, but your banker is not so sure. You can talk about potential, but lenders want to see the diagnostic reports on the health of your business. You feel caught in the Catch-22 because you don’t have the flexibility to produce reports that provide the needed information most effectively to make your case for financing.


Your answer to a patient who asks about best practices for treating his ailment today is different that it was a decade ago. So too is the answer for how to bring Business Intelligence to your healthcare organization ( http://www.kianoff.com/solutions/industries/healthcare/ ).


If any of these triggers sounds like your current operation, maybe it’s time for a checkup on your systems. Integrating your patient billing with today’s powerful business management and accounting systems gives visibility into what services are profitable – when, where and how. In one place you have the complete view of the business side of your organization and all the critical revenue and operational information you need to manage it effectively. You do want to keep that practice healthy!


Lisa Kianoff is Founder and President of Kianoff & Associates.