Newsletter 68 September
05
Malpractice Filings Against Health Care Providers, Jan 2001 – Jul 2005
Boutique/Concierge Medical Practice
Clark County Health District Disease Statistics – July 2005
By Ron Kline, MD,
2005-2006
Installation Speech
Dear Friends and Colleagues;
My thanks and appreciation for joining me on this night. As a veteran of many "dress up" nights such as this, I know that most of us, after a long week, would rather be curled up in our shorts with a good book. Your presence here tonight speaks of the respect you have for our society. So on behalf of the Clark County Medical Society, and myself I thank you for the respect and appreciation you have shown through your presence tonight.
I am
humbled and flattered to be chosen by my peers to serve as the leader of the
2500 physicians of
The
presence tonight of seven former presidents of the Clark County Medical Society
gives this night special meaning. I am
also pleased that three of these former presidents are physicians at
Comprehensive Cancer Centers of
We have
come a long way in a few short years.
Just a few years ago, we were but a few weeks away from bankruptcy. Who can forget the debacle of the 2003
Special Session on Malpractice when even our loyal friends told us that we
appeared unprepared, disorganized, unprofessional and fragmented. Rather than uniting under the banner of the
Clark County Medical Society or the
I have spent a fair bit of time reflecting on our victories in 2004. Where did our political power come from? Unlike the unions, we cannot place hundreds of our members on the streets knocking door to door for our candidates. Although we have gotten better at donating to political campaigns, we are still miserly in comparison to the trial attorneys who view campaign contributions as the simple cost of preserving a status quo that they benefit from. I sincerely believe that our political power comes from the fact that our patients trust us, they trust us with their lives and with their children's lives; and they trust us when we actually take the time and effort to tell them that certain political issues are of vital concern to us. We spend our days trying to do good for others and that fundamental meaning of our life's work translates into the respect that society still holds for us in a very cynical world.
During the 2004 election cycle, many of us, through the incredible help of Annette Mohs, put banners in our offices telling our patients about our support for Question 3, and our opposition to Questions 4 and 5. Many of my patients spoke to me about Questions 3, 4, and 5, and I like to think the thousands of similar conversations that occurred in doctor's offices throughout the state was part of the reason for the victories that we secured. Just as we must learn from our mistakes, we must also learn from our successes. We must once again plan to place banners in all of our offices announcing to our patients our support for various candidates and questions in the next and subsequent election cycles.
Some of you may have noted, as I did, in the recent movie "Batman Begins," that Bruce Wayne's father, a man who cared about his family, taught his son well, and cared about the world around him, was a physician. He wasn't a plaintiff's lawyer, a managed care executive or a hedge fund manager. We are fortunate that the physicians who have gone before us have set an example to be emulated. From the doctor of 100 years ago driving his horse drawn buggy in the middle of the night to deliver a baby, to the 21st century physician using all of the high tech tools at his disposal to save a life, we are valued by the world around us. (Ever play the lifeboat game… the doctor always gets to stay on board and the lawyers get fed to the sharks). But we must be careful not to squander this hard earned respect that has been acquired over the course of a century, one physician at a time, one patient at a time. It is not only the meaning of our lives and our profession, but also the source of our political power. We must, in organized medicine, strike the balance between protecting our interests, and our patient's interests. If we lose sight of this balance then the respect our professional has enjoyed for a century will soon dissipate into the morass of special interest groups all clamoring for attention
But, while we celebrate our victories, we cannot rest on our laurels. Our elected and highly political supreme court still must pass judgment on Question 3. Many states have celebrated the passage of malpractice reform, only to
see it struck down by their state supreme courts. As such, the 2006 election cycle will be as critical as the 2004 cycle. We won Question 3 in 2004; let's not lose it in the Supreme Court elections of 2006. Let me further remind all of you that were it not for the courage of Secretary of State Dean Heller last year in confronting a Nevada supreme court that was contorting itself in every way possible to prevent the voters from even getting a chance to vote on malpractice reform, Question 3 would not have even made it to the ballot. Dean Heller is running for congress next year. He has told us that the trial lawyers intend to make an example of him for opposing them on Question 3. Let's send a clear message to the trial bar, that we support our friends and remember them at election time.
As a
medical society, we must also work to nurture the medical community that has
thrived in
a notch on their corporate bedpost.
As a
medical society, we must forge links with other groups in
In all of
these efforts we must be together rather than fragmented. This brings me to my final point. Only one third of doctors in
I would like to close with a quote from Vincent Van Gogh who said, "Great things are not done by impulse, but by a series of small things brought together."
In the busyness and small actions and events of our everyday lives it is sometimes hard to remember that it is the sum of those actions that give both direction and meaning to our lives and to the organizations in which we take part.
I thank you for joining me on this very special night, and will work hard to live up to the goals that I have set for myself tonight. Thank you.
2005-06
Bylaws, Policies & Procedures -
CME Committee - Ed Kingsley, MD
Comm Relations/Comm Health - Jerry Jones, MD
Credentials Committee - Carol Van der Harten, MD
Government Affairs - Ron Kline, MD
Membership - Mark Doubrava, MD
MedPac - David Steinberg, MD
Mini-Internship -
Nominating Committee - Frank Nemec, MD
2001 2002 2003
2004 2005
Jan 39 33 108 61 41
Feb 20 14 98 72 63
Mar 35 30 169 123 64
Apr 37 34 111 81 70
May 37 35 126 65 14
Jun 27 24 103 90 65
Aug 54 51 76 67
Oct 37 83 110 59
Nov 38 184 59 78
Sum
372 823
1246 867
Congratulations and Welcome to the
If you have any pertinent information about the following membership
candidates, please contact:
· Reuel M Aspacio, MD - Dermatology
· Iulia C Ionitoaia-Chaudhry, MD - Internal Medicine
· Jerry J Marty, MD - Anatomical/Clinical Pathology
· Mark R Parson, MD - Radiology
· Randall E. Yee, DO - Orthopaedic Surgery
For information on becoming a member of the
call Marlaina Burns at 739-9989.
***New Member Special*** $390 New members can join for half
price their first year.
By Weldon (Don) Havins, M.D.,
Esq., CEO, Special Counsel
Some physicians, tired of seeing more patients for less reimbursement, are considering medical practice changes which would reduce their patient load and provide more time to evaluate and treat patients in a caring manner. Entrepreneurial medical organizations have solicited physicians to enroll in their plans to implement these practice modifications. There may be legal pitfalls in some of these plans, including violating the fundamental principle that additional charges are not permitted for traditional, covered medical services. Plans which do not violate state and federal insurance laws address non-covered services only, usually providing priority access not otherwise required in traditional medical service plans.
Medicare regulations provide that participating physicians (PARs) are limited to the RBRVS payment amount for covered services (including deductibles and copayments). Non-participating physicians (non-PARs) are paid 95% of the RBRVS and may collect no more than a total of 115% of the RBRVS. Physicians who violate these limitations are subject to exclusion from the Medicare program and severe civil monetary penalties. Concierge/boutique practice arrangements must avoid any income related to "covered services".
In 2002,
then HHS Secretary Thompson received a formal complaint letter signed by
several Congressmen charging that MDVIP, a
An Office
of Inspector General (OIG) Alert issued on
Physicians who "opt-out" of the Medicare program must clearly communicate to Medicare patients that the physician does not participate in the Medicare program and that all medical care rendered will be on a "fee for service" basis. A physician who opts out of Medicare must do so for all patients (and for Medicare payments from any source, direct or indirect) and must do so for a minimum of two years. There are very few physicians who voluntarily opt-out of Medicare and practice on a cash basis. Those doing so have no need for concierge/boutique arrangements because they can incorporate these fees into their cash charges.
In some areas of the country, where concierge/boutique practices are becoming increasingly common, some insurers are inserting provisions into their contracts with providers precluding a contracted provider from charging patients anything more than the contract payments. The validity of these clauses has not been resolved in the courts. The question becomes whether a provider can be precluded from contracting with patients regarding issues not related to medical services rendered. Opponents of the insurer clauses contend that these clauses violate the right to contract guaranteed in the U.S. Constitution.
May an HMO or PPO patient contract for special access services, not involving covered medical services? Can an HMO patient contract with a physician to be seen within 5 minutes of his or her appointed visit time and have access to a special reception area ("waiting room") where refreshments are served by a solicitous, attractive attendant, and where computer email and telephone service are available? What if the concierge contract specifies that the patient will be guaranteed same day appointments for non-emergent medical complaints, and 24 hour access to the specific (not the "on-call") physician through provision of the physician's home phone number, cell phone number, and pager number? These are not benefits covered under an HMO or PPO medical services contract. These services appear ripe for a concierge-type contractual arrangement.
The increasing costs of medical insurance are forcing progressively greater percentages of our population into managed care plans. These plans attempt to control costs by, among other methods, contracting with physicians through capitation limitations or through reduced reimbursement contracts. Physicians' costs are increasing and they must generate more revenue to cover these costs and maintain profitability. The most common method of "increasing efficiency" is by seeing more patients with less time spent with each patient. Foreseeably, patient waiting times, for and at appointments, will continue to grow longer. Patients with sufficient means increasingly will be willing to pay to minimize the inconveniences associated with this system. Should a patient be precluded from contracting to minimize the time inconveniences, and be guaranteed access to his or her specific, preferred physician? Physicians considering converting to a concierge/boutique practice anticipate that they will be able to maintain the same income, spend more time with patients, and reduce stress in their lives. Patients participating in a concierge/boutique practice anticipate they will have more access and convenience than would otherwise be available to them.
Plan One requires physicians to reduce their total patient load to 600 patients per physician. Those patients pay, for example, $3000 per year for participation in the plan. The entrepreneur organizing corporation takes $1000 for their efforts, leaving the physician $2000. The physician then provides all medical services for that $2000 for that year regardless of the number of patient visits or time required to care for the patient. Patients are provided an annual physical. Any lab tests, hospitalization costs, or consultation fees are the responsibility of the patient and the patient's medical insurance. Patients are guaranteed same day appointments with "no wait" upon arriving at the physician's office.
This model appears to place the physician into serving as an insurer. Medical insurance characteristically is paid for medical services, to be provided in the future, with financial risk borne by the insurer. Plan One requires payment for medical services ($2000), in the future (the $2000 in advance of rendering services), with the physician assuming the risk of patients over-utilizing the medical services provided. Plan One appears to have all three fundamental characteristics of insurance. Insurers are regulated by the State Division of Insurance. The approval process for insurers is daunting and very expensive, and mandated by statutes and regulations. Plan One appears to violate state insurance laws.
Plan Two is similar to Plan One, but seeks to avoid violation of state insurance laws by having the patient pay the
money into an escrow account which then is paid to the physician at the end of the year. This Plan addresses the future medical services issue. However, the payment for medical services and assumption of risk issues remain. The Plan risks a Commissioner of Insurance “cease and desist order” as well as fines for unauthorized operation of an insurance product. Medicare laws appear violated by utilization of this plan.
Plan Three requires a reduction in patient load to 600 patients per physician. Patients incur an annual cost of around $1500. The consulting company takes $500 and the physician retains $1000. The physician bills for medical services provided in the usual manner. The contract strictly provides for only "non-covered" services, chiefly same day appointments and minimum wait times in the medical office. Access to the physician via home telephone and cell phone numbers is available 24 hours a day. Unless the physician is out of town, patients are guaranteed that they will communicate with and see their preferred physician. This type of plan seeks to avoid violation of Medicare and state insurance laws, and appears to do so.
Plan Four involves a per visit access fee. This concierge service does not require the involvement of a consulting organization. Patients are given the option, payable in advance of their visit, to pay for concierge services. The patient paying for this option can choose the most convenient time and date for their appointment and gain nearly immediate access to the physician upon arriving for the visit. Medical insurance is billed in the usual fashion. This plan does not appear to violate state insurance laws or or Medicare. Patients here are paying only for priority access.
Plan Five varies from plan Four in that the patient pays an annual fee, in advance, for the concierge services which includes 24 hour direct telephone access (home and cell phone) to their preferred physician. A special reception area with refreshments may be provided. The advantage of this plan is that the patient is assured of V.I.P. access status for all visits, regardless of the number of appointments in that annum.
Plan Three is the current, "traditional" concierge/boutique medical practice. Physicians limit their income by capping the number of patients in their practice. Since all patients must utilize the concierge/boutique plan, there may be a lag in reaching the 600 patient maximum. This can substantially adversely impact physician revenue. Patients are billed normally for covered medical services. Physicians may experience times of office inactivity when
there is no demand for services. However, patients report being very satisfied with this plan.
Plans Three and Four do not require the physician to reduce his or her practice to 600 patients total. Non-plan patients reportedly are sometimes annoyed by V.I.P. patients "jumping the cue" to receive priority access. Some physicians have established separate reception areas for V.I.P. patients to minimize this problem.
Physicians are facing progressively decreasing revenues, decreasing satisfaction with private practice, and increasing stress. Patients are increasingly complaining about perceived impediments to accessing their physicians. Concierge and boutique contractual plans are a potential solution for those with the means to afford them.
Physicians opting for participation in concierge/boutique arrangements may face criticism for helping to develop a two tier system of access to medical services based on an ability to pay. Physicians using these plans can expect reactions from the philosophical and political egalitarians who will take umbrage at the notion of priority access to health care.
Is the developing system of priority access to medical services an unacceptable aberration from our current health care distribution system, or is the concierge/boutique concept a reasonable mechanism to compensate physicians for progressive reductions in governmental and private insurance reimbursements?
Some physicians compare this priority system to that existing in many airlines’ “executive clubs.” Airline passengers arrive at the destination at the same time although those utililizing, for a price, the executive clubs find the traveling experience much more pleasant.
By Donald Kwalick,
MD, MPH, Chief Health Officer
Clark County Health District continues efforts to
control
For the
first time last year,
Clinical Features of
Clinical Features of Severe Disease (
Typically
the second season has proven to be more severe for
The health district has partnered with the Nevada State Health Division to conduct three categories of surveillance:
Mosquito abatement activities received a boost when the Clark County Vector Control program was transferred to the health district. This allows for a more streamlined program and personnel have greater authority to conduct abatement activities under public health provisions contained in Nevada Revised Statutes.
While
several mosquito pools have tested positive for West Nile Virus, as of
The health
district has also launched a new
The health
district is offering these resources in an effort to make it easier for the
public to learn more about
Mark Your Calendars!
This is the first time in (who can remember?) years that
this meeting will be held in
1. A half day Scientific Session
2. President’s Luncheon (usually has an interesting speaker)
3. Very Informative Governmental Affairs Meeting
4. Reference Committee meetings where resolutions are discussed and perfected to become policy
5. Dinner and Awards ceremony where the NSMA and NSMAA Presidents are inaugurated
This year the
Delegation Chair for
BOARD OF TRUSTEES
MEETING
Tuesday,
Minutes Synopsis
The minutes for the
June meeting were approved unanimously.
Financial Report
Dr. Steinberg
reported the
Proposed Budget
The Council approved
the proposed budget.
Membership Report
Dr. Kline reported there
were 756 dues paid members, which was an increase over the 743 last year and
112 dues exempt members. There were 54
new members for the fiscal year and 25 reinstatements.
Health District Report
Dr. Kwalick was
unable to attend the meeting but sent a report to the Board on current Health
District topics.
Dr. Forman gave a
report regarding the
Credentials Report
The following 5
members were approved for active membership: Jay E Coates, DO - Surgical
Critical Care; Peter W DeBry, MD - Ophthalmology;
There was 1
reinstatement, Steven D Lampinen, MD - Family
Practice. Two Student Members were
approved for membership: Mark D Berner -
NSMA Report
Dr. Evins stated the
NSMA works by commissions like
AMA Report
Dr. Nelson referred
to this month's
New Business
Dr. Kline announced
the passing of member Jean Migliorato, MD, family practice physician.
NV
Dr. Kline reported a
meeting was held with Mayor Goodman to discuss the AMC proposal. They will meet with the
Administrative Report
Dr. Havins is to ask
the CEO of Allscripts to present more information to the Board.
Committee Appointments
Dr. Kline announced
his Committee Chair appointments which were ratified by the Council.
The next BOT meeting
will be on
For Lease: 4000(+/-) sq ft,
For
MOONLIGHT MEDICINE: A unique, well established medical practice seeking a Nevada Licensed FP or GP looking to supplement income working 1, 2, or 3 days per week. Flexible hours and/or schedule as well as competitive salary. Fax CV to (702) 974-0108.
Office space available
HOUSE FOR
Physician Reviewers Needed: HealthInsight,
the Quality Improvement Organization for the Medicare Beneficiaries of the
state of
Members can advertise (up to 40 words) three times a year in
the
Bechtel
NV Chapter AACE 434-8400
10/7 thru 10/9 -
“Endocrinology for the Non-Endocrinologist (at
Pri-Med Institute (877) 4PRI-MED
Southwest Medical Associates 242-7735
9/8 - “Office
Dermatology”
UMC 383-2604
9/13 - “Heparin
Induced Thrombocytpenia”
9/27 - “What’s New
in Vascular Surgery”
Only CME Activities held at the
CLARK
COUNTY HEALTH DISTRICT
DISEASE STATISTICS*
- July 2005
DISEASE
CASES REPORTED YEAR TO DATE
July
2004 July 2005 2004 2005
VACCINE
PREVENTABLE DISEASES
DIPTHERIA 0 0 0 0
HAEMOPHILUS
INFLUENZA 2 0 5 10
HEPATITIS A 1 1 4 4
HEPATITIS B 5 4 36 16
INFLUENZA 0 0 53 119
MEASLES 0 0 0 0
MUMPS 0 0 0 0
PERTUSSIS 0 2 2 22
POLIOMYELITIS 0 0 0 0
RUBELLA 0 0 0 0
TETANUS 0 0 0 0
SEXUALLY
TRANSMITTED DISEASES
AIDS 20 11 169 134
CHLAMYDIA 524 494 2222 3342
GONORRHEA 259 202 1202 1437
HIV 10 27 136 177
SYPHILIS
(Early Latent) 2 3 6 16
SYPHILIS
(Primary & Secondary) 35 12 14 70
ENTERICS
AMEBIASIS 0 1 7 9
BOTULISM-INTESTINAL
0 0 0 0
CAMPYLOBACTERIOSIS 16 7 45 45
CHOLERA 0 0 0 0
CRYPTOSPORIDIOSIS 0 0 1 4
E. COLI
O157:H7 0 1 4 10
GIARDIA 6 4 35 28
ROTAVIRUS 14 22 485 386
SALMONELLOSIS 11 10 59 71
SHIGELLOSIS 2 4 20 28
TYPHOID
FEVER 1 0 1 0
VIBRIO 3 0 4 0
YERSINIOSIS 0 1 0 1
OTHER
ANTHRAX 0 0 0 0
BOTULISM
INTOXICATION 0 0 0 0
BRUCELLOSIS 0 0 0 0
COCCIDIOIDOMYCOSIS 5 4 34 38
ENCEPHALITIS 0 0 0 2
HANTAVIRUS 0 0 0 0
HEMOLYTIC
UREMIC 0 0 0 0
SYNDROME(HUS)
HEPATITIS C 0 0 2 0
HEPATITIS D 0 0 0 0
LEGIONELLOSIS 0 2 3 9
LEPROSY 0 0 1 0
LEPTOSPIROSIS 0 0 0 0
LISTERIOSIS 1 0 4 0
LYME
DISEASE 0 0 0 0
MALARIA 1 0 4 0
MENINGITIS,
ASEPTIC/VIRAL 3 9 30 41
MENINGITIS,
BACTERIAL 0 0 7 7
MENINGOCOCCAL
DISEASE 2 1 4 5
PLAGUE 0 0 0 0
PSITTACOSIS 0 0 0 0
Q FEVER 0 0 0 1
RABIES
(HUMAN) 0 0 0 0
RELAPSING
FEVER 0 0 0 0
ROCKY MTN
SPOTTED FEVER 0 0 0 0
RSV 5 7 1027 1265
TOXIC SHOCK
SYNDROME 0 0 2 2
TOXIC SHOCK
SYN 0 0 2 2
(STREPTOCOCCAL)
TUBERCULOSIS 7 6 41 52
TULAREMIA 0 0 0 0
UNUSUAL
ILLNESS 0 0 2 0
(ENCEPHALITIS)
*Numbers include confirmed and probable cases.
Annette Mohs, the Mortgage Group…363-3993
American Society of Bariatric Physicians…..303-770-2526
Brazill Team/Remax…204-6191… www.TheBrazillTeam.com
Business Funding Solutions ….. 248-3016 ….. www.businessfundingsolutions.net
CB Richard Ellis…369-4800… www.cbre.com
Colonial Bank ….. 304-3770 ….. www.colonialbank.com
Consultants in Marketing….944-2464
DMSL Medical Management & Billing Service ….. 558-2326
Doctors Pavillion…222-4304
Machabee Office Environments…260-0555… www.machabee.com
Mason Medical Management …..458-2455….. no website
Medical Group Management Association ….. 697-5471 ext. 134
Medical Liability Association of
Nevada First Bank ….. 310-4000 ….. www.nevadafirstbank.com
Nevada Mutual Insurance Company ….. 798-6001 ….. www.nevadamutual.com
Matthew Passalacqua, Financial Advisor ….. 254-1263 ….. www.tricorfinancialservices.com
Priority One Commercial ….. 228-7464 ….. www.priorityonecommercial.com
Protrans ….. 877-6333 ….. www.protranslv.com
Red Rock Medical Billing….942-4117
Red Rock Radiology ….. 731-2888 ….. www.redrockradiology.com
Rose-Glenn Group….Nevada State Bank ….775-827-7311
Saguaro Home Health…..248-6850…..no website