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Practice Productivity
Michael Delac, CMPE
Vice Chair, RPA Practice Managers Committee

One of the many challenges a Practice Manager faces is ensuring their entire practice maintains high levels of productivity at all times. Typically in practice management, the term “productivity” is used to define and measure the quantity of work a clinician generates within a specific amount of time. Although this is the most important area of practice production, every member of the practice must be productive in order for the practice to truly reach optimal performance as a “well oiled machine”.

Practice productivity is much more complex than simply analyzing the X’s and O’s. Productivity is an attitude you must instill in everyone in the practice; high levels of work, balanced with high quality work. It all begins with you! As the practice leader, you must consistently exemplify that you are willing to produce high quality/ high levels of your job-specific duties and tasks, without hesitation, without complaints, everyday. Once accomplished, you can then hold everyone in your practice to the same high quality/high level production standards you have (and have proven to them) relative to their individual job-specific duties, tasks and responsibilities. In other words, lead by example, not just because you’re the “boss”.

It would be unrealistic however, to think that everyone will be 100% productive 100% the time. Each person within your practice will be faced with distractions that can deter productivity: Family concerns, health concerns, financial concerns, inter-office conflicts, worries about lunch plans, and the list is endless. Inevitably, these distractions exist, however as a leader it is your responsibility to help create an environment that allows appropriate channeling of these diversions to minimize their affect on maintaining practice productivity. Support the employee whose child got in trouble at school to handle the situation; if you don’t, that employee will be thinking about their child the rest of the day. How productive will they really be then? Encourage the employee who just got off the phone with an upset patient to discuss the conversation with you; listen and allow them to vent; they will feel much better about speaking to the next patient. Building this type of environment will help foster productivity in spite of these distractions.

Another key component to productivity is measuring and monitoring the production of each position within the practice, allowing objective evaluation of performance to take place: Clinicians can be measured by encounters, charges, revenue, RVUs, etc; collection and billing staff can be measured by A/R, net collections, claim submissions, rejections, etc.; administrative staff can be measured by their attendance and punctuality, confirmations, prior authorizations, referrals, etc; and of course, the Practice Manager can be measured by the success or failure of all of these components as an integrated whole.

Michael Delac, CMPE, is the Practice Manager for Macon Medical Group, in Macon, Georgia, and Vice Chair for the RPA’s Practice Managers Committee. If you would like to contact Mike, he can be reached at or (478) 973-6164


Practice Management
"Study: Bundling to Cut Health Costs Is Hard to Achieve"
"The Coding Controversy and the AHA"
"Patient Satisfaction Gets Renewed Focus With Medicare Changes"
"Physicians Using Tablets to Treat Patients"
"Stage 2 of Meaningful Use Moved to 2014"
"Managing Your Online Presence"
"How Providers Can Make PHRs Relevant"

In the News
"MMF Found Superior for Lupus Nephritis"
"CellCept Beats Azathioprine in Lupus Nephritis"
"Role of Inflammatory Related Gene Expression in Clear Cell Renal Cell Carcinoma Development and Clinical Outcomes"
"ASN: Declining GFR Linked to Mortality Risk After MI"
"Portable Home Dialysis Unit Improves QoL"
"AlloCure Drug Could Help Treat AKI"
"Beyond the Abstract - Effect of Renal Function on Urinary Mineral Excretion and Stone Composition"
"Psychiatric Issues for Patients With Renal Disease"
"Telephone Intervention Can Help Obese Patients Lose Weight"
"Toxic Component in Herbal Remedies Linked to Kidney Failure"
"Abatacept May Benefit Some Lupus Nephritis Patients"

Practice Management

Study: Bundling to Cut Health Costs Is Hard to Achieve
Renal Business Today (11/03/11)

Despite an interest in bundling payments to healthcare providers to encourage cost-cutting, implementing the strategy has been more difficult than expected, according to a new RAND Corporation study. This study looked at the first three years of a major effort designed to test the bundled payment approach to healthcare financing. In this approach, doctors, hospitals, and other health providers share one fee for treating all aspects of a procedure, such as a hip replacement or diabetes. In theory, health providers are encouraged to work together to eliminate unnecessary care and improve quality. Three years after the launch of the PROMETHEUS Payment project in three U.S. communities, no bundled payments had been made and no payment contracts for bundled payments executed. All parties involved in the effort are committed to its success, but researchers say the slow progress indicates challenges that complex payment reforms must overcome. Peter Hussey, the study's lead author and a policy researcher at RAND, noted, "The model is very complex and the fact that it builds upon the existing fee-for-service payment system presents challenges." The new findings were published in the November edition of Health Affairs.

The Coding Controversy and the AHA
Modern Healthcare (11/21/11) Conn, Joseph

Two separate but related announcements—that the American Medical Association would oppose ICD-10 deployment and that the Centers for Medicare and Medicaid Services would postpone enforcement of its rule requiring use of the Version 5010 data standards—has shaken the healthcare industry overall and its information technology sector specifically. American Hospital Association vice president of policy Don May reports that while 5010 increases the efficiency of the billing process, "we're concerned about how this delay of enforcement might work." May also says ICD-9 is outdated and the transition to a new system is necessary, but he concedes that "hospitals are dealing with ICD-10, meaningful use, accounting for disclosures, bundled payments for accountable care organizations—there are a lot of overlapping burdens put on that same IT department."

Patient Satisfaction Gets Renewed Focus With Medicare Changes
Physicians Practice (11/17/11) Koniver, Craig

In October 2012, as part of the federal healthcare reform, Medicare will begin using patient satisfaction scores to calculate a portion of hospital reimbursements. This means that regardless of patient outcomes, hospitals will be paid less if patients are unhappy with the care they received. To provide better care and improve patient engagement, doctors will have to make some changes. They could implement integrative medicine, like massage or acupuncture, especially since patients are spending their money on such treatments already. Doctors also should practice their communication skills, such as using positive body language and listening attentively, and they should make an effort to communicate with patients through blogs, Facebook, and YouTube. By focusing on patient satisfaction, doctors can forge a partnership with patients, who will trust them and seek their advice. Doctors must remember that patients want to be heard, supported, and validated, and paying more attention to patients ultimately will boost their revenue and job satisfaction.

Physicians Using Tablets to Treat Patients
Computerworld (11/17/11) Mearian, Lucas

A recent survey of 350 healthcare providers and administrators by the Computing Technology Industry Association finds that close to 50 percent of doctors will employ tablets and other mobile devices to access electronic medical records (EMRs) and perform other tasks in the coming year. Tablets already are being used by 25 percent of the providers polled, and 21 percent will begin using the devices in the next year. Meanwhile, 20 percent of respondents plan to use smartphones to access EMRs, following in the footsteps of 33 percent of those who do so already. The federal government is pushing for more than 50 percent of healthcare providers to have electronic health record (EHR) systems in place by 2014, with those demonstrating meaningful use receiving tens of thousands of dollars in reimbursement money. The survey indicates that EHR systems will be in place in 58 percent of small practices by the end of 2012. Additionally, 38 percent of providers have deployed comprehensive EMRs, with 61 percent stating that they are satisfied with their systems, and 17 percent have partial systems or modules in place. However, only 5 percent use cloud services, and just 10 percent plan to use video conferencing to interact with patients in the coming year.

Stage 2 of Meaningful Use Moved to 2014
Health Data Management (11/11) Goedert, Joseph

The start date for Stage 2 of the electronic health records (EHRs) meaningful use program has been pushed back from 2013 to 2014 by the Department of Health and Human Services so that Stage 1 pioneers who attest in 2011 are not punished by narrow timeframes next summer for preparing for Stage 2. Under the Medicare and Medicaid EHR Incentive Programs, providers who attest early receive greater incentives. And now those providers who first attest in 2011 can get three payment years for meeting the Stage 1 expectations, while those first attesting in 2012 can only get two payment years under Stage 1 criteria.

Managing Your Online Presence
Modern Medicine (10/10/11) Phairas, Debra; Porciuncula, Ashley

Physicians should proactively manage their online presence after creating a Web site. They should know what patients are saying about them, their group, their staff and their practice; and once a month should assess reviews on Yelp and physician-rating Web-sites, correct misconceptions and respond proactively to complaints. Physicians should Google themselves to make sure their telephone number and address is accurate and up-to-date; should have a picture with a warm, smiling face taken by a professional; and should have a profile written in a patient-friendly manner that includes their philosophy, how they treat patients, and even hobbies or interests that would make them more approachable. The Web site should be consistent with their brand with regard to a standard logo, color palette, style of the practice and office materials, but developing a unified brand also has legal ramifications. Joining social networking sites such as Facebook, Twitter, LinkedIn can give physicians a face, but policies and procedures for the use of social media by their staff will be needed. Blogging can give physicians an opportunity to discuss something newsworthy or medical issues, and can offer another way to increase their search ratings. Physicians also should provide links to other medical sites as well as to their profiles on TV or radio, in newspapers and online magazines.

How Providers Can Make PHRs Relevant
HealthLeaders Media (11/01/11) Freeman, Greg

Personal health records (PHRs) must have relevance for both the patient and the healthcare provider, and many providers opt to have the PHR tethered to the electronic medical record so that the data can be connected automatically. "A shared connection [between patients and physicians] is what consumers really want," says the University of Pittsburgh Medical Center's G. Daniel Martich, MD. Engaging both patients and doctors in using the PHR involves educating both parties through tutorials or incentives such as contests, as UPMC has done; Holly Miller, MD, with MedAllies reports that patients with the most diagnoses are likeliest to use a PHR, while participation can be encouraged by permitting patients to link with others, as many patients like being part of a virtual community of people with the same diagnosis.

In the News

MMF Found Superior for Lupus Nephritis
Renal and Urology News (11/28/11) Charnow, Jody A.

Mycophenolate mofetil (MMF) is superior to azathioprine as maintenance therapy for patients with active lupus nephritis (LN), new research suggests. Scientists conducted a 36-month randomized, double-blind study of 227 LN patients. MMF was found to decrease significantly the time to treatment failure, which was defined as death, end-stage renal disease, doubling of serum creatinine level, renal flare, or rescue therapy for LN. Overall rates of treatment failure were observed to be 16.4 percent among the 116 patients who were randomized to oral MMF (1 g twice daily) and 32.4 percent among the 111 patients randomized to oral azathioprine (2 mg/kg/day). This difference means a 59-percent decreased risk of treatment failure for patients in the MMF group. During the six-month induction trial, study subjects received either oral MMF or intravenous cyclophosphamide. Compared with patients on azathioprine, patients treated with MMF had a 50-percent lower risk of renal flare and a 61-percent lower risk of needing rescue therapy. The rates of serious adverse events were not significantly different between the groups, although the rate of study withdrawal related to adverse events was significantly higher with patients taking azathioprine. The researchers wrote that MMF is superior to azathioprine for maintaining the renal response to treatment and in preventing relapse in patients with active LN who also responded to induction therapy with either MMF or IV cyclophosphamide. Study findings were published in The New England Journal of Medicine.

CellCept Beats Azathioprine in Lupus Nephritis
MedPage Today (11/17/11) Walsh, Nancy

Maintenance therapy with the immunosuppressive agent mycophenolate mofetil (CellCept) is superior to azathioprine for preventing renal relapse among patients with lupus, according to the results of a phase III trial. Patients randomized to receive mycophenolate mofetil had a hazard ratio for treatment failure of 0.44 compared with patients randomized to azathioprine, according to the research team led by Dr. Mary Anne Dooley of the University of North Carolina in Chapel Hill. Those who received mycophenolate also were less likely to experience a renal flare, the researchers reported in the Nov. 17 New England Journal of Medicine. The researchers conducted a double-blind randomized study with 227 patients who had active lupus nephritis at baseline. Those who responded to 24 weeks of induction therapy with oral mycophenolate or intravenous cyclophosphamide were assigned to receive maintenance therapy with either mycophenolate (1 g twice daily) or azathioprine (2 mg/kg/day). Efficacy was consistently greater in patients who received mycophenolate mofetil, regardless of their induction therapy, race, or geographic location. Only about 8 percent of patients in both groups were in complete remission at the end of the induction phase, but many improved in the 36 months of the continuation phase, with complete remission experienced by 62.1 percent and 59.5 percent of those in the mycophenolate mofetil and azathioprine groups, respectively.

Role of Inflammatory Related Gene Expression in Clear Cell Renal Cell Carcinoma Development and Clinical Outcomes
UroToday (11/16/2011) Tan, W.; Hildebrandt, M. A.; Pu, X.; et al.

Renal cell carcinoma is the eighth most common cancer in the United States, with clear cell renal carcinoma its most common type. Scientists have found that inflammation gene expression could serve as biomarkers for the risk of recurrence and death among patients with clear cell renal carcinoma. The investigators analyzed a panel of 661 inflammation-related genes taken from tumor and adjacent normal tissues of 93 patients. The study identified differential expression patterns between tumor and normal tissues. Researchers found 151 genes with at least a two-fold change in gene expression between adjacent normal tissue and tumor, of which most were up-regulated in tumors. There were 20 total genes that were significantly associated with recurrence and/or overall survival; these were chosen for further validation. High expression of GADD45G was significantly associated with a 2.09-fold increased risk of recurrence while high CARD9, NCF2, and CIITA expression was significantly associated with a 2.52-fold, 2.26-fold, and 2.11-fold increased risk of death, respectively.
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ASN: Declining GFR Linked to Mortality Risk After MI
MedPage Today (11/16/11) Bankhead, Charles

Patients with chronic kidney disease (CKD) are at greater risk of death after myocardial infarction, with the risk increasing as glomerular filtration rate declined, according to a review of 103,000 myocardial infarction patients. Excess mortality risk ranged from 17 percent to 500 percent, depending on the severity of CKD. Mortality risk can be reduced by revascularization procedures across all CKD categories, scientists reported at the American Society of Nephrology meeting. Worsening CKD, however, lowered the likelihood of coronary intervention. The researchers noted that further studies are needed to clarify the efficacy and effectiveness of revascularization procedures after MI in patients with renal impairment. This new study included data from the Myocardial Ischemia National Audit Project, with records of MI patients treated at 242 National Health Service hospitals in England and Wales. The analysis included 41,931 patients with ST-elevation MI and 61,302 patients with non-ST segment elevation MI.

Portable Home Dialysis Unit Improves QoL
Renal and Urology News (11/16/11) Cho, Stephan

Patients with end-stage renal disease who used a portable hemodialysis (HD) system for 12 months experience improved quality of life (QoL), researchers reported at Kidney Week 2011. The patients in the study rated their QoL on a 10-point Likert scale (0 = worse, 10 = best). The score rose a significant degree, from 6.4 at baseline to 7.0 at the end of the study. Patients who used the NxStage System One, a home use HD system approved by the U.S. Food and Drug Administration, were less likely to return to their previous dialysis regimen and reported greater satisfaction with physical intimacy. These are the latest findings from the ongoing Following Rehabilitation, Economics and Everyday-Dialysis Outcome Measurements (FREEDOM) study, which looks at the clinical and economic benefits of daily home HD treatments. The NxStage System One is manufactured by NxStage Medical, Inc. based in Lawrence, Mass.

AlloCure Drug Could Help Treat AKI
Renal Business Today (11/16/11)

A new therapy under development by AlloCure may be an effective treatment for patients with acute kidney injury (AKI). A Phase I clinical trial in 16 subjects found that the AlloCure therapy, AC607, was safe and well tolerated, and that treated subjects experienced a lower incidence of AKI, reduced length of hospital stay, and reduced hospital readmission rates compared to controls. Researchers presented their findings Nov. 12 at the American Society of Nephrology annual meeting in Philadelphia. The new AC607 is comprised of adult bone marrow-derived mesenchymal stem cells. The therapy targets the injured kidney and mediates an anti-inflammatory, organ-repair process. AC607 also is not recognized by the immune system, allowing it to be used in an "off the shelf" paradigm without blood or tissue typing. A Phase II trial of AC607 is scheduled to begin in 2012. In the Phase I trial, none of the study subjects experienced severe adverse events attributable to AC607 treatment. Trial subjects were matched to a cohort of historical controls according to sex, race/ethnicity, co-morbid conditions, and other risk factors for AKI. Hospital readmission rates were 6.3 percent compared to 12.5 percent for AC607-treated subjects and historical controls, respectively.

Beyond the Abstract - Effect of Renal Function on Urinary Mineral Excretion and Stone Composition
UroToday (11/16/2011) Kadlec, Adam O.

Past research has found a bidirectional association between chronic kidney disease and nephrolithiasis, where the existence of one is liable to show the presence of the other. Investigators have also noticed that renal function can affect stone composition. To examine any patterns between renal function and stone composition, researchers used a large clinical database of patients who underwent endourologic intervention. Data showed that differences in estimated glomerular filtration rate (eGFR) were significantly associated with differences in stone composition. There was a close link between renal function and uric acid content of stones. Patients with a "normal" eGFR (>90 cc/hr) only had a 3-percent chance of forming a stone made primarily of uric acid. Good renal function appeared to be protective against uric stones. Calcium phosphate stones, however, were not commonly seen in patients with poor renal function. The number of calcium oxalate stones was not associated with urinary calcium, urinary oxalate, or calcium oxalate supersaturation index. Researchers also found that uric acid excretion did not differ between patient groups, and that supersaturation indices were unable to explain the high rate of uric acid stones in some patients. The study also found that calcium oxalate content and the frequency of calcium oxalate stones did not correlate with eGFR, possibly because calcium oxalate stone formers have extra-renal etiologic factors, including absorptive hypercalciuria or enteric hyperoxaluria. The study added to the literature on the etiology of metabolic stone disease and influences on stone composition, an area that still requires clinical and basic research.
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Psychiatric Issues for Patients With Renal Disease
Psychiatric Times (11/16/11) Fanton, John H.; McIntyre, Roger S.; Cohen, Lewis M.

Psychiatrists are often asked to medicate patients with chronic kidney disease, a population that is on the rise in the United States. The Physicians’ Desk Reference routinely recommends partial dosages of psychotropic medications for renal patients, but the data used to support these recommendations remain limited, especially for children. When prescribing psychotropic medications, psychiatrists must be aware of the effects of renal dysfunction on medication absorption, volume of distribution, metabolism, and excretion of the drug and respective metabolites. Because the intermediate products of metabolism are difficult to identify, drug metabolism is one of the least-familiar areas of pharmacokinetics. Providers who wish to prescribe medications for this patient population must consider the unique physiological, pharmacokinetic, dynamic, and risk/benefit factors. Psychiatrists may need to collaborate with primary care providers and nephrologists to prescribe psychotropics. Most psychotropics are not metabolized or excreted by the kidneys, and so most of these types of medications are well tolerated, when prescribed with caution.
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Telephone Intervention Can Help Obese Patients Lose Weight
Renal and Urology News (11/16/11) Stein, Jill

Weight-loss programs delivered by telephone can be just as effective as programs delivered in person, according to the results of a study with 415 obese patients with at least one cardiovascular risk factor. Researchers reported the findings at the American Heart Association Scientific Sessions 2011, as well as online in the New England Journal of Medicine. Patients who enrolled in a weight-loss program delivered over the phone by health coaches and Web site and physician support lost weight and kept it off just as well as patients who participated in a program that had in-person coaching sessions. Both interventions were compared to a control group that received only brief advice. About 40 percent of patients in both groups lost 5 percent or more of their initial body weight, compared to about 20 percent in the control group. A 5-percent weight loss has been found to produce health benefits that include improved control of diabetes and hypertension and decreased cardiovascular risk factors. Patients in the study sustained the weight loss for two years.

Toxic Component in Herbal Remedies Linked to Kidney Failure
Renal Business Today (11/10/11)

Aristolochic acid, a plant component long used in herbal remedies, can cause kidney failure and upper urinary tract cancer in exposed individuals. Balkan endemic nephropathy, a disease limited to rural areas in the Danube river basin, is characterized by progressive kidney failure and often includes the development of urothelial cell carcinomas (UUC). Aristolochia clematitis, also known as "birthwort," often grows in local wheat fields. A research team led by Dr. Arthur Grollman, Distinguished Professor of Pharmacological Sciences, Stony Brook University School of Medicine, reported the association after a study of patients in Croatia, Bosnia, and Serbia with Balkan endemic nephropathy. The findings, which explain the 50-year-old mystery as to the cause of this disease, are reported online in Kidney International. The study results show that dietary exposure to aristolochic acid is related to endemic nephropathy and UUC in genetically susceptible individuals.

Abatacept May Benefit Some Lupus Nephritis Patients
Renal and Urology News (11/14/11) Schieszer, John

The addition of abatacept to mycophenolate mofetil (MMF) and steroids can significantly improve the time needed to complete renal response in patients with lupus nephritis (LN), researchers reported at the 2011 American College of Rheumatology annual meeting. Among nephrotic LN patients, however, researchers noted an improvement in proteinuria with abatacept, which indicates that additional exploration may be needed into potential biologic activity in these patients. Abatacept, a selective T-cell co-stimulation modulator, is already approved for rheumatoid arthritis and is now under evaluation as a treatment for LN. Researchers, led by Dr. Richard Furie, Chief of the Division of Rheumatology and Allergy-Clinical Immunology at the North Shore-Long Island Jewish Health System, conducted a 12-month, Phase II/III double-blind study in patients with active ISN/RPS Class III or IV LN. All patients received MMF (a target dose of 1.5–3.0 g/day) and up to 60 mg/day of prednisone or an equivalent. Patients then received placebo or IV abatacept, with the primary efficacy endpoint of time to complete renal response confirmed at 30 days after the first response. A total of 228 LN patients completed 12 months of treatment. The time to CRR was not significantly different between groups for abatacept 10/10 and 30/10 compared with placebo. A subset analysis of 122 nephrotic patients found an approximately 20 percent to 30 percent greater reduction in urinary protein to creatinine ratio in patients randomized to abatacept compared with placebo from month six to month 12.

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December 2011