Monday, March 28, 2016

The Rise and Potential Consequences of Using Advanced Practice Providers

Utilization of APPs (advanced practice providers) or MLPs (mid-level providers) such as nurse practitioners and physician assistants, has increased geometrically all across the medical field. The APPs have filled huge gaps in medical care and have performed quite well. However, with growth comes the concerns and responsibilities of supervision, training, continuing education, and liability.

The recent article Medical Supervision of Mid-Level Providers written by a malpractice insurance company contains an extensive list of concerns. They are:
·         Ensuring proper credentials.
·         Delineating scope of practice.
·         Being sure a MLP’s clinical activities do no exceed the supervising physician’s Clinical privileges.
·         Teaching sufficient communication skills to the MLP.
·         Conducting regular and periodic reviews of the MLP’s activities and clinical responsibilities.
·         Encouraging each MLP to seek supervising physician oversight as needed; encouraging questions.
·         Require MLP badge identification to make credentials clear and avoid misunderstanding.
·         Provide patients a mechanism to access the supervising physician, if they choose or request.
·         Be familiar with local laws related to the scope of practice and supervision requirements for MLPs.
·         Be sure each physician who oversees MLP activities is authorized/approved to provide supervision.
·         Ensure that the MLP is properly trained for the nuances of your individual practice setting.
·         At least yearly, review/update MLP job descriptions, policy statements, practice protocols, collaborative and employment agreements.
·         Keep a copy of the collaborative agreement on file in each practice location where the MLP works.
·         Develop and approve guidelines concerning prescriptive practices. At minimum, the guidelines should:
o    Identify the supervising/collaborating physician(s);
o    Identify the types of medications to be prescribed as well as limitations;
o    Define provisions for managing emergencies; and
o    Specify the frequency of reviewing prescriptions written for controlled substances.
·         Regularly review and update protocols for frequently encountered clinical problem(s).
·         Plan scheduled meetings with each MLP at least monthly for the first six months and at least quarterly thereafter or as often as otherwise required by state-specific requirements.
·         Document any clinical problems discussed and a plan for improvement.
·         Be sure that professional liability insurance includes coverage for MLPs.
·         Contact your malpractice carrier immediately whenever adding MLPs.
While this may seem to be quite an extensive list, it is actually the same general conditions under which most physician providers function. Additional suggestions are:

1.    Make sure that the chain of responsibility of the supervising physician is specifically spelled-out, and understood by all.
2.    Be careful of having different malpractice vendors for MLPs and supervising physicians. This can generate adversarial situations when a case appears.  
3.    Have clear, specific policies regarding when the MLP should ask for an immediate consultation.
4.    Make sure APPs do not identify themselves as doctors, even if one has a PHD. Juries are sensitive to potential misrepresentation.
5.    Send your APP to specific courses for the care setting in which you work. Remember how practical knowledge comes with time, but is not innate.
6.    Understand your malpractice coverage. A consultant may help make sure everyone is adequately covered. The APP needs to be named on the policy.
7.    Have a cordial and professional relationship with your APP.
8.    Avoid allegations of fraud by following CMS billing guidelines; your degree of clinical involvement in any case should never be overstated.

Times are changing and it is important to adapt to the new realities. The Advanced Practice Provider is the political answer to lack of access to health care for the near future.

Monday, March 21, 2016

Motivation for Building a “McMansion”

In the article one weird reason why doctors buy bigger homes than lawyers, it explains a seemingly common practice in locations in certain tax protected states that physicians purchase more expensive homes to protect their assets from malpractice liability.

The article states that doctors buy bigger homes than lawyers in general.  Protection of assets by buying an expensive dwelling in place like Florida and Texas is a well-known strategy that many people in the top 5% use very creatively.  There are multiple homes sitting on the coastline with few regular dwellers. A former commissioner of baseball used this strategy quite effectively. 
The sad part is that people have to go to such lengths in our litigious society to protect their lifetime assets and protect the future of their families.

A seemingly simple solution for the medical profession would be to radically alter the malpractice system from a personal fault system to a reasonable no-fault system that compensates the injured appropriately. It would also punish egregious repeated behavior by some practitioners through appropriate sanctions. Other countries like New Zealand have accomplished this with some success.
The ultimate solution is not to get sued either individually or in a group. Unfortunately, the odds are against you. On the other hand, a nice house on the beach is nicer than living in a tent.

Monday, March 14, 2016

Avoiding Retirement Planning Mistakes

Entering retirement is potentially a time of less stress, reinvigoration, reimaging oneself, travel, and reinventing oneself. The major problem with this is it takes enough money to navigate retirement comfortably.
The article Top 10 Retirement Planning Mistakes lists 10 technical reasons that lead to poor planning and execution. The big ones are not saving soon enough, not anticipating inflation and taxes, unpredictable medical expenses, retiring with excessive debt, and not understanding the rules of disbursement of funds.
Social Security and Medicare should not be the cornerstone of any retirement plan but an adjunct.

My associates and I have made significant errors in planning, predicting the future, and learning how to live on a budget.
The following are some classic errors to which I am party to many.

1.      Not realizing you may live 20 years past retirement.

2.      Owning and still paying off expensive homes and cars.

3.      Paying everybody else’s bills. The children though grown are still on the dole.

4.      Not saying “NO” to everybody on your payroll.

5.      Not treating the disease of fixed expenses before it is too late.

6.      Getting divorced.

7.      Thinking retirement planning is not a dynamic enterprise, but due to longevity changes from year to year.

8.      Trying too hard to leave a decent inheritance. Informing your relatives that any money spent now is money they will not get in the future.

9.      Getting off the endless need to buy more and more. If you shopped in your own closet, you will find things that are back in style.

10.   Avoiding get rich schemes.

11.   Establishing limits on credit card usage. Calculate how much money a person can spend a day. This brings harsh reality to bear.

12.   Not staying in physical shape.

13.   Not getting help in picking the best Part B Medicare supplement as the cost differs wildly.

14.   Getting advice on when to take your social security check. This is a very individual decision.

15.   Going out to dinner instead of lunch. Lunch menus are significantly cheaper. Drink at home.

16.   Learning the rules of mandatory distribution of IRA’s at 70 and ½.

17.   Not divesting your investments in a common sense orderly fashion. Certain investments should be liquidated before others.

18.   Not warning your children that you may have to move in with them if they keep asking for money.

19.   Not leaving a will or estate planning. If you hate your family, this is a good plan.

20.   Being realistic about potential health costs. Even healthy people can easily spend greater than 6 figures their last year of life. Hopefully your insurance will cover this.
Bottom line is to enjoy life and retirement. Do not be plagued with the constant worry of money. Remember, your relatives and dependents can always get a job.

Monday, March 7, 2016

Using Yoga (or Pilates) to Restore Your Health

The article Restorative Yoga Poses articulates with pictures how to restore the body and maintain and improve fitness.

Yoga can be used as an organized way to improve strength, flexibility, balance, psychological relaxation, and a way to age gracefully.

When walking by a yoga class, the first impression is that you have to be really fit to participate and you do not want to make a fool out yourself. The reality is yoga practice is on a continuum and changes according to your level of experience and fitness.

The biggest challenge is walking in the room and participating. Nobody is watching you except the instructor and the practice is an experience not a competition.

A new student will quickly discover how out of shape they truly are and the potential for fitness, weight loss, and stress reduction. I am usually the fattest person in the room and have lost >20 pounds in 2 years. My balance is dramatically improved and twist sufficiently to back the car down the driveway.

The advantage of a class format is that the most unmotivated person’s challenge is only attendance. The fitness workout takes care of itself. The upper body, core strength, flexibility, and lower body strength will automatically improve over time.

I wish I had begun when I was fifty and not waited till Medicare age. This can be a senior citizen’s panacea to chronic pain, equilibrium, balance, and terrible upper body strength. Start with a few restorative classes and easily progress to better health. The spiritual side can be a life-guiding support system and can easily add to the improved physical health.  

For those who do not wish to incorporate a spiritual component within their exercise program, there is the equally restorative Pilates, named after its founder Joseph Pilates.  Pilates training is very available, perhaps even more-so than yoga. All of the benefits noted for yoga apply. While some Pilates exercises require use of devices (the main one called a “reformer,” though it has nothing to do with discipline!), there are also mat Pilates exercises that can be learned online (YouTube), which can easily be performed in one’s living room.

Whichever you choose, Yoga or Pilates, it is wise to take a bit of time each day to pursue one of these, especially as aging advances (which it does!).  These two body-training programs will help keep you sane, flexible (in body anyway), and able to negotiate gravity, which (regardless of its newfound waves) seems always ready to find ways to trip us up.  Be wise, have fun, and pick one of them.