Tax & Insurance Impact of
Affordable Care
Brian Meyers, CPA
Anders Health Care Services
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2013 Tax Update
Jessica A. Johnson, CPA
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Agenda
• Fiscal Cliff Tax Changes
• Affordable Care Act
Tax Implications
• Examples
• Questions
• Planning
Considerations
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The New Law
• American Taxpayer Relief Act of 2012
– Passed by Congress Overwhelmingly Jan 1, 2013
• Bush tax cuts made permanent for families with less
than $450k of taxable income
• Delayed the sequester (billions of dollars in acrossthe-board spending cuts) for another two months.
– New legislation made sequester cuts permanent
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2013 Tax Brackets
(Married Filing Jointly)
Marginal Income Ranges
Tax Rate
$0 – 17,850
10%
$17,850 – 72,500
15%
$72,500 – 146,400
25%
$146,400 – 223,050
28%
$223,050 – 398,350
33%
$398,350 - $450,000
35%
Over $450,000
39.6%
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History of Tax Brackets
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Capital Gains/Dividends
• Capital Gains and Qualified Dividends
– 20% - For taxpayers in the 39.6% Bracket
– 15% - For taxpayers in the 25% - 35% Brackets
– 0% - For taxpayers in the 10 or 15% Brackets
• Qualified Dividends not taxed at ordinary
income rates.
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Alternative Minimum Tax
• Permanent patch introduced, adjusted for
inflation each year
• 60 million taxpayers spared from AMT
Payroll Tax Increase
• FICA taxes
– 6.2% Social Security – Employee and Employer
– 1.45% Medicare – Employee and Employer
• Payroll Tax “Holiday”
– 2011 and 2012
– 4.2% Social Security – Employee Contribution
• 2013 – 6.2% Social Security Employee
Contribution is back
Itemized Deduction Phase Out
• “Pease Limitation” of itemized deductions is
reinstated
• 3% phase out of itemized deductions for
married couples with AGI in excess of $300k
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Personal Exemption Phase Out
• “PEP phase out” of 2% of for each $2,500 or
portion there of by which AGI in excess of
$300K
• PEP completely phased out for AGIs exceeding
$425k
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Misc. Individual Items
• Child tax credit extended permanently
– $1,000 maximum per child
• Child and dependent care credit permanently
extended
– Credit available for up $6,000 of expenses per family
• American Opportunity Tax Credit – extended
through 2017
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Estate & Gift Tax
• Permanent 40% maximum estate/gift tax rate
• 2013 estate/gift tax exclusion - $5.25 million
– Inflation-adjusted annual amount
• Portability made permanent
• 2013 Gift Tax Exclusion - $14,000
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Business Tax Provisions
• Accelerated Depreciation
– IRC 179 Deduction was increased to $500k on the
first $2 million of purchases
– 50% Bonus depreciation
• R&D Credit extended through 2013
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Affordable Care Act – 2013 Tax
Changes
• New 3.8% Surtax on investment income
– The tax will be imposed on the lesser of
• Net investment income
• The excess of AGI over $250K for married couples
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Affordable Care Act – 2013 Tax
Changes
• New 3.8% Surtax on investment income
Subject to Surtax
Wages
Exempt from
Surtax
X
Taxable Interest
X
Capital Gains
X
Exempt Interest
X
Dividends
X
Annuity Income
X
Passive Income
X
Rents
X
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Affordable Care Act – 2013 Tax
Changes
• Additional 0.9% Medicare tax on earned income
– Employee’s portion subject to additional tax for
earned income exceeding $250K for married couples
• Additional withholding from wages begins at $200K
– Applies to earned income from flow through activities
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Individual Case Study
2012
2013
$355,000
$355,000
Investment Income
50,000
50,000
Long Term Capital Gains
20,000
20,000
Passive Income
20,000
20,000
100,000
100,000
Wages & SE Income
Non-passive Income
Less Adjustments
Adjusted Gross Income
(15,067)
$529,933
Itemized Deductions
$(60,000)
Personal Exemptions
(7,600)
Taxable Income
$462,333
(15,067)
$529,933
$(53,102)
$476,831
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Individual Case Study
• 2012 Tax - $127,090
• 2013 Tax - $140,224
• Increase of $13,134
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Individual Case Study
$2,274
American Taxpayer Relief
Act
$5,595
Affordable Care Act
Other
$5,265
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Planning Considerations
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Minimize AGI
• Harvest capital losses
• Minimize income from IRA distributions
• Don’t forget any Schedule C, Schedule E, or Schedule
F expenses
• Utilize any above-the-line deductions
– Contributions to HSAs, self-employed retirement
accounts, and traditional IRAs
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Minimize NII
• Invest in tax-exempt bonds
• Minimize investing in securities that pay dividends
• Increase participation to make passive income nonpassive
• Convert passive income to salary (however, then
exposed to .9% payroll tax)
• Capital loss harvesting
• Installment sales
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Affordable Care Act
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Overview
• Acts passed in 2010
• Patient Protection and Affordable Care Act
• Health Care and Education Reconciliation Act
• Political environment
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Tax and Regulatory Changes
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Current Changes
•
•
•
•
Provide dependent coverage up to age 26
Remove co-pays for certain prevention and care
Tax credits available to small employers
Rebates provided for not meeting medical loss
ratios
• Nutritional content disclosure
• 10% tax on indoor tanning
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Additional Regulations
•
•
•
•
•
•
Pharmaceutical companies
Insurance companies
Hospitals
Medicare/Medicaid
Tort litigations
Medical device
manufacturers
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More Tax Changes
• HRA, FSA, HSA or Archer MSA
– Disallowed OTC drugs not prescribed
• Tax on nonqualified distributions from HSA or
MSA increases to 20%
2013 Changes
• Limit FSA contributions to $2,500/year with
COLA adjustment
• Additional tax on wages and investment
income for individuals
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2014 Insurance Reform
• Individual Mandate – all US citizens and legal
residents required to have health insurance
• Create Exchanges for insurance
• No denial for “pre-existing conditions"
• Employers with >200 employees automatically
enroll in health insurance plans
• Out-of-pocket, premium and deductible limits
• Limit waiting period for coverage
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Insurance Rebates
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Insurance Rebates
• Rebates to employers when medical loss ratios
are not met
• 85% of premiums must be spent on claims or
health care quality improvement
• 80% for small-group and individual markets
• States can establish higher MLR standards
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Insurance Rebates
• Rebates issued to employer for group plans
• Determine whether or not the rebate must be
distributed
– Subject to ERISA?
– Who pays premiums?
– Were premiums pre-tax or after-tax?
– Terminated/separated employees
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Small Employer Health
Insurance Credit
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Health Insurance Credit
•
•
•
•
•
•
Small Employers
Provide health insurance to employees
25 or fewer employees
Average annual wages less than $50,000
Aggregation rules apply
Estimated 4 million businesses eligible, only
228,000 taxpayers took advantage
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2010-2013 Credit
• Full credit for 10 or fewer employees with
average wages up to $25,000
• Employer must contribute at least 50% of
premium for all employees
• Max. 35% of employer contribution to
insurance premiums
• Limited to 25% for NFPs
• Not applicable to employer contributions to
HSAs, FSAs, etc.
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Up to $25,000
$30,000
$35,000
$40,000
$45,000
$50,000
Up to 10
35%
28%
21%
14%
7%
0%
11
33%
26%
19%
12%
5%
0%
12
30%
23%
16%
9%
2%
0%
13
28%
21%
14%
7%
0%
0%
14
26%
19%
12%
5%
0%
0%
15
23%
16%
9%
2%
0%
0%
16
21%
14%
7%
0%
0%
0%
17
19%
12%
5%
0%
0%
0%
18
16%
9%
2%
0%
0%
0%
19
14%
7%
0%
0%
0%
0%
20
12%
5%
0%
0%
0%
0%
21
9%
2%
0%
0%
0%
0%
22
7%
0%
0%
0%
0%
0%
23
5%
0%
0%
0%
0%
0%
24
2%
0%
0%
0%
0%
0%
25
0%
0%
0%
0%
0%
0%
Source: Congressional Research Service, Summary of Small Business Health Insurance Credit Under PPACA (P.L. 111-148) 3
(Apr. 5, 2010)
Firm Size
2014-2015 Credit
• “Guaranteed” through 2013 plus a maximum
of 2 consecutive years after
• Credit amount rises to max 50% (35% for
NFPs)
• Only insurance purchased from Exchanges will
qualify after 2013
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Up to $25,000
$30,000
$35,000
$40,000
$45,000
$50,000
Up to 10
50%
40%
30%
20%
10%
0%
11
47%
12
Slide #94 from CCH
37%
27%
17%
7%
0%
43%
33%
23%
13%
3%
0%
13
40%
30%
20%
10%
0%
0%
14
37%
27%
17%
7%
0%
0%
15
33%
23%
13%
3%
0%
0%
16
30%
20%
10%
0%
0%
0%
17
27%
17%
7%
0%
0%
0%
18
23%
13%
3%
0%
0%
0%
19
20%
10%
0%
0%
0%
0%
20
17%
7%
0%
0%
0%
0%
21
13%
3%
0%
0%
0%
0%
22
10%
0%
0%
0%
0%
0%
23
7%
0%
0%
0%
0%
0%
24
3%
0%
0%
0%
0%
0%
25
0%
0%
0%
0%
0%
0%
Source: Congressional Research Service, Summary of Small Business Health Insurance Credit Under PPACA (P.L. 111-148) 3
(Apr. 5, 2010)
Firm Size
Calculating the Credit
• Report on Form 8941
• Test for eligibility
• Average wages = Total wages / FTE
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Calculating the Credit
• Determining full-time equivalent employees
– Do not count
•
•
•
•
•
•
Self-employed individuals
Partners
2% shareholders for S corps
5% owners of C corps
Many relatives of above
Seasonal workers
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Calculating the Credit
• Determining full-time equivalent employees
– Total hours of service for all eligible employees by
2,080
– Non-hourly employees are capped at 8 hours/day
and 40 hours/week
– Each employee capped at 2,080 hours
– i.e. 10,500 total hours = 5 FTE employees
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Calculating the Credit
• Determining wages
– All wages paid during the taxable year
– Includes OT and bonuses
– All wages subject to FICA (not limited to wage
base)
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Credit Example
• Facts
–
–
–
–
5 Employees
Total Hours in 2012: 7,000
Total Wages in 2012: $60,000
Total Employer Paid Premiums: $6,000 (all single coverage)
• 7,000/2080 = 3 FTE
• $60,000/3 = $20,000 Average Annual FTE Wages
• $6000 X 35% = $2,100 total credit
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Employer Mandate
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Employer Mandate
• In 2014, an “applicable large employer” may be
liable for an “assessable payment” if it “fails to
offer its full-time employees (and their
dependents) the opportunity to enroll in
minimum essential coverage under an eligible
employer-sponsored plan.”
• Imposed for any month at least one covered
employee obtains coverage eligible for premium
tax credit or cost-sharing benefits
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Applicable Large Employer
• Employer who employed an average of at
least 50 full-time equivalent employees on
business days during the preceding calendar
year.
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Employees
• Full-time employee average at least 30 hours per
week*
• Seasonal workers excluded up to 120 days
• FTE = Hours of all part-time divided by 120*
• Safe harbors – IRS Notice 2012-58
• Aggregation rules
• Owner-employees not excluded from
determining “applicable large employer” status
*Further guidance yet to be released
Dependents
• Minimum Essential Coverage must be offered
to employees and dependents
– Children up to age 26
– Parents
– Siblings
– Other relatives and in-laws
– Member of household
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Penalties
• More likely the less employer contributes
• Won’t be imposed on part-time employees –
under 30 hours
• Both the $2,000 and $3,000 penalties will be
adjusted for inflation
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All-Employee Penalty
• $2,000 “all-employee” penalty for employers
failing to meet “minimum essential coverage”
• $2,000 X (# Full-Time employees – 30)
• Penalty only applies to Full-Time Employees
• BUT use Full-Time Equivalents to determine if
employer is “applicable large employer”
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All-Employee Penalty
• Watch classification of independent
contractors
• Cost-benefit analysis of providing insurance
• Look for further regulations to be issued
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Per-Employee Penalty
• Once minimum essential coverage is offered to
full-time employees (and their dependents), the
penalty is only assessed on the number of fulltime employees who actually enroll through
Exchanges and receive a premium tax credit or
cost-sharing reduction.
• $3,000 per employee not to exceed “allemployee” penalty
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Example of All-Employees Penalty
Full-Time Employees
Minimum Essential Coverage
80
Other*
10
Total
90
*One of the “other” employees certified for premium tax credit.
Penalty Calculation
Total Full-Time Employees
Less Reduction
Base for penalty
Penalty
90
(30)
60
x 2,000
$120,000
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Example of Per-Employee Penalty
Full-Time Employees
Minimum Essential Coverage*
90
Other
0
Total
90
*One of the employees certified for premium tax credit.
Penalty Calculation
Total Full-Time Employees
Less Reduction
Base for penalty
Max Penalty
Penalty
($3,000 x 1)
90
(30)
60
x 2,000
$120,000
$3,000
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Questions
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Planning Considerations
• Review your current coverage
• Determine if you need to make changes
• Watch for updates
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Brian Meyers
Anders Health Care Services
(314) 655-5500 (Office)
bmeyers@anderscpa.com
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Comments?
leagueofhealthcareexperts.com/worksmarter
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Practical Applications of
Technology
Al Klein
Managing Member
Omniscient HC
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Making Data Work for You
•
•
•
•
•
How Data Is Stored In Your System
Types of Systems
Pros and Cons
Addressing the Current Challenges
Tackling a “Simple” Report
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How Data Is Stored In Your System
• Databases
– Good at organizing and managing data
– Can be Networked or File-Based
– In Healthcare, these can be very large systems
– Standardized methods to store and retrieve data
– Prepare data for other purposes
• Reporting
• Exchange between systems and other organizations
• Processing for downstream processes
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How Data Is Stored In Your System
• Tables
– Example: Patient
PatientID
1
2
3
4
5
6
7
8
LastName
Smith
Jones
Williams
Johnson
Brown
Smith
Thompson
Young
FirstName
Robert
Joan
Thomas
Eileen
Andrew
Robert
Nathan
Beth
DOB
4/5/1933
8/14/1957
11/29/1966
7/13/1922
1/19/1972
9/9/1949
5/14/1939
12/18/1979
SSN
111-22-3333
123-45-1234
453-75-8939
782-55-8392
832-71-5738
312-63-6332
183-98-6765
583-81-5721
Gender
M
F
M
F
M
F
M
F
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How Data Is Stored In Your System
• Relationships
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How Data Is Stored In Your System
• Constraints
– Keys (Primary and Foreign)
PatientID
1
2
3
4
5
6
7
8
4
LastName
Smith
Jones
Williams
Johnson
Brown
Smith
Thompson
Young
Green
FirstName
Robert
Joan
Thomas
ileen
Andrew
Robert
Nathan
Beth
Michael
DOB
4/5/1933
8/14/1957
11/29/1966
7/13/1922
1/19/1972
9/9/1949
5/14/1939
12/18/1979
6/19/1949
SSN
111-22-3333
123-45-1234
453-75-8939
782-55-8392
832-71-5738
312-63-6332
183-98-6765
583-81-5721
844-48-4833
Gender
M
F
M
F
M
F
M
F
M
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How Data Is Stored In Your System
• Constraints
– Foreign Keys (Referential Integrity)
Not in the
Patient Table
PatientID
1
2
3
4
5
6
7
8
LastName
Smith
Jones
Williams
Johnson
Brown
Smith
Thompson
Young
FirstName
Robert
Joan
Thomas
Eileen
Andrew
Robert
Nathan
Beth
DOB
4/5/1933
8/14/1957
11/29/1966
8230
1/19/1972
9/9/1949
5/14/1939
12/18/1979
SSN
111-22-3333
123-45-1234
453-75-8939
782-55-8392
832-71-5738
312-63-6332
183-98-6765
583-81-5721
ProcedureID
1
2
3
4
5
6
7
PatientID
1
5
7
3
22
2
7
CPTCode
99213
99212
37000
93829
98112
99214
37000
ProcedureDate
2/1/2013
2/5/2013
2/9/2013
3/1/2013
3/3/2013
3/17/2013
2/9/2013
Physician
3
6
1
7
2
2
1
Gender
M
F
M
F
M
F
M
F
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How Data Is Stored In Your System
• Constraints
– Data Integrity
ResultID
1
2
3
4
5
6
7
PatientID
3
6
1
2
2
8
3
LabDate
3/1/2013
3/3/2013
3/8/2013
3/15/2013
3/18/2013
3/20/2013
3/22/2103
ResultDate
3/3/2013
3/5/2013
3/10/2013
3/17/2013
3/20/2013
3/22/2013
3/24/2103
Result
17
47
Normal
18
132
Fail
Result cannot be Empty
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How Data Is Stored In Your System
• Storage / Retrieval
– Data is stored in the order it is added
– General truths
•
•
•
•
Adding new data is unaffected by the volume of data
Updating existing data is affected by the volume of data
Data is NOT typically retrieved in the order it is stored
Retrieving existing data is affected by the volume of
data
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How Data Is Stored In Your System
Deletes - BAD
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How Data Is Stored In Your System
• Indexes
– Reorganizes Tables Into More Searchable Formats
– Makes It Easy To Locate and Retrieve Data
– Enables Keys and Constraints Previously
Mentioned
– Pose a Risk / Reward Conundrum for Storage /
Retrieval
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How Data Is Stored In Your System
• Enterprise Database Features
– Triggers
• “Event-Driven” Code that “Fires” When Data Is Inserted
/ Updated / Deleted
– Stored Procedures / Functions
• Code Executed by the Database During Queries and
Batch Processing
– Risk / Reward Conundrum for Efficiency / Data
Integrity
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Types of Systems
• Transactional
– Record Data Line-by-Line
– Highly Configurable
– Built for Storing Events and Easy Expansion
– Typical Type Used by EMR / EPM
– Not Good for Reporting and Aggregation
– Envision A Credit Card Statement (the details)
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Types of Systems
• Reporting / Aggregation
– Summarizes Data from Transactional Data
– Highly Indexed
– Stores Calculated Data to Increase Efficiency
– Built for Reporting and Summary
– Quick Access to Ad-Hoc Data
– Requires “TLC”
– Envision your Car Dashboard
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Types of Systems
• Your Report Server
– Many EPM / EMRs Use Copies of the Transactional
System
– This is NOT a Reporting / Aggregation System
So Why Do We Have It?
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Types of Systems
• Your Report Server
– Supports non-Real-Time Reports (Batch)
– Reduces Load on Production Transactional System
– It is “Impossible” to Tune a Transactional System
for Efficient Storage and Reporting…
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Addressing The Current Challenges
…But We Can Try!
How?
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Addressing The Current Challenges
• Improving Access To Data
– Build a Data Warehouse
• “True” Reporting / Summary System
• Can Be a Large Project
• Can Be Expensive and Time Consuming
– Tune the Reporting Server
• Can Be Affected by Copy Process
• Can Affect Other Reporting Processes if Done in a
Vacuum
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Addressing The Current Challenges
• Improving Access To Data
– Hybrid
• Develop Small Warehouse(s) for As Many Purposes as
Possible in Reporting Server
• Ensure Tuning is Replicated by Copy Processes
• Do Enough to Make a Warehouse Without Really
Making a Warehouse
• Be Strategic By Keeping In Mind The Initiatives Adhead
of You
• Look Around You To Ensure You Are Not Duplicating
Efforts
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Addressing The Current Challenges
•
•
•
•
•
•
Meaningful Use
Patient-Centered Medical Home
Accountable Care Organization
HEDIS
NCQA
What Else? / What’s Next?
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Addressing The Current Challenges
• Strategy
–
–
–
–
What Do These Have In Common?
What Can We Do For All of These at the Same Time?
What Is Completely Distinct From One Another?
What Can We Build To Support What We Know and What
We Expect?
– Can We Build It With Buy-In From Relevant Groups?
– Can We Support It Without Affecting Others?
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Tackling A “Simple” Report
• PCMH Requirement – “Daily Huddle”
– Data Elements
•
•
•
•
•
•
•
•
Next Day Appointments
Patient Demographics
Prior Appointment Date
Critical Diagnoses
Date of Last Vitals
Values of Last Vitals
Date of Last Important Procedures
Values of Last Important Procedures
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Tackling A “Simple?!” Report
• PCMH Requirement – “Daily Huddle”
– Data Elements
•
•
•
•
•
•
•
•
Next Day Appointments
Patient Demographics
Prior Appointment Date
Critical Diagnoses
Date of Last Vitals
Values of Last Vitals
Date of Last Important Procedures
Values of Last Important Procedures
Yikes!
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Tackling A “Simple?!” Report
• How To Go About Doing This Report
– These Elements Are Easy
• Demographics
• Next Day Appointments
– These Elements Are Moderately Easy
• Critical Diagnoses
– These Elements Are Hard
• Anything with “Last” in the Description
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Tackling A “Simple?!” Report
• Why Are These Things Moderate or Hard?
– Location and Variability in Storage of Data
• Visit Tables / Orders Tables / Procedures Tables /
Images Tables / Labs Tables
– Identification of Appropriate Rows
• Lab Codes and Descriptions / CPT Codes and
Descriptions / ICD-9(10) Codes and Descriptions /
Images Codes and Descriptions
– The Word “Last” Adds Complexity
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Tackling a “Simple?!” Report
• What Does “Last” Mean to ME?
– Diagnoses and Procedure Data Is Usually Stored In
The Same Table
– It Is Very Difficult to Find The “Last” Time for
Anything In A Transactional Table in a Single Query
– It Is More Difficult to Find The “Last” Time AND
THEN The “Last” Value in a Single Query
(You Know This to Be True By How Much Hand Waving I Am Doing)
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Tacking a “Simple?!” Report
• What To Do?
– Write A HUGE Monolithic Query That Gets All The
Data At One Time
– Write a Bunch of Views That Make the Monolith
Look Less Scary
– Create a Table (or set of tables) That You Maintain
to Store This Data In A More Retrievable Format
and Use Them to Build the Report
(What do you think we prefer?)
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Tackling A “Simple?!” Report
• And the winner is…Building Tables
– Not A “True” Reporting / Aggregation System but
it Gets Us Closer
– Removes the Complexities of Monolithic Queries
– Will Perform Much Better
– Will Require Maintenance (good and bad)
– WILL BE REUSABLE FOR OTHER STUFF!
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Questions?
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Alfred Klein
Managing Member
Omniscient HC
314.581.8941 (m)
a.Klein@nomeneo.com
www.nomeneo.com
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Comments?
leagueofhealthcareexperts.com/worksmarter
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Enhancing Customer Service
Through Improved
Communication Skills
AMG Group
League of Health Care Experts
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Objectives for Today
• Be more aware of role of active listening in
effective communication
• Better understand personal listening
strengths and improvement opportunities
• Explore research and models for handling
difficult conversations with patients
• Discuss the value of customer service in
medical settings today
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
"Five-Star Customer Service: A Step-by
Step Guide for Physician Practices."
• Patients who are treated with kindness
and respect are more loyal
• They are also more likely to refer their
friends, which helps sustain growth.
• But the biggest benefit of delivering a
positive patient experience, perhaps, is the
legal buffer it provides.
Jim Saxton, chairman of the healthcare litigation group for Stevens & Lee law firm in
Lancaster, Pa, Published on Physicians Practice (http://www.physicianspractice.com)
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
The onus falls on practice
managers
• To develop concrete policies and training programs
that create a culture of service excellence
• "You need to measure where you are, but it can be
as simple as asking patients to fill out a one-pager at
check out"
• Brown's staff, which created their own patient and
employee satisfaction surveys, makes them available
online and in their clinic, including their physical
therapy offices and surgical waiting room —
prompting patients to fill them out by offering monthly
drawings for a $50 gift card
Managing Up
• Put that next staff member, whether it's someone in our
billing office or one of our providers, in a positive light to
our patients so we're already relieving them of any
stresses they may have about their appointment
• Share something important about an employee's position,
or what the provider or employee does particularly well
• 'This provider has been with us for 15 years and he has
excellent patient care,' or 'May I have you step down and
Debbie will assist you with your check out. She's
excellent with scheduling,"
Gastroenterology Specialists of
Oregon in Oregon City
• "I gave them each $5 one morning and told them their
homework assignment was to go out and find a business
in our community that they felt has a significant impact
on our community and to try and figure out why they
have such success,”. Some went to Starbucks, others to
McDonald's or Jamba Juice. "Part of the assignment was
for them to observe how their business was run and
what customer service nuggets of wisdom they could
walk away with that we could apply in our own
business," she says. "What they wrote down and
observed was awesome."
The First 10
“Stickers for staff members to wear that say “Remember the first 10”It's a low cost way to remind them how important those first 10
seconds are with a patient," he says. "First impressions make a big
difference."
• Reward
• You'll get better buy-in from your staff, of course, if you reward for a
job well done. Brown uses a quarterly bonus. "One of the core
components of that bonus is patient satisfaction and that is derived
directly from the survey score," he says. "All of the employees are
aware that they're being measured on how well the patients are
taken care of and how happy the patients are. That can be
powerful."
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
How do we make a good first
•
•
•
•
•
•
impression?
Adjust your attitude
Straighten your posture
Smile
Make eye contact
Raise your eyebrows
Shake hands. This is the quickest way to establish rapport. It’s also
the most effective. Research shows it takes an average of three
hours of continuous interaction to develop the same level of rapport
that you can get with a single handshake
• Lean In
• Goman, Carol K, Forbes.com, Feb. 2011
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Customer service culture all begins
with leadership
"It's got to start from the top with leadership making a conscious decision that
they're going to make this part of the employee evaluation, get their staff
trained, and integrate it into their practice"
• be both "consistent and pervasive." "Consistently means not just when you
feel up to it, but that you can turn it on even during your most demanding
stressful times, and pervasively means it's not just the doctor or the
receptionist but every single person on your staff”
• It's worked out well for Alabama Orthopaedic Clinic, which has grown its
business in seven of the past eight years — revenue was temporarily flat
during one of those years due to the economic downturn. "We're one of the
only surgical orthopedic groups that get more referrals from former patients
than we do from physicians," boasts Dean Brown, administrator of Alabama
Orthopaedic Clinic. "For us, it's all about word of mouth.“
•
Shwartz, Shelly K; Physicians Practice, March 2011
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Listening Skills
Active Listening
– What’s different about it?
– What gets in the way?
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Listening
• Listening is combination of what we
–Hear
–Understand
–Remember
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Communication by the
Numbers
• ___% Body
Language
• ___% Tone of
Voice/Pace
Words
Tone/Pace
Body Language
• ___%
Words
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
% of Message Conveyed
Via Body Language
1. 15%
2. 43%
3. 55%
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% of Message Conveyed
Via Voice Tone/Pace...
1. 18%
2. 38%
3. 49%
% of Message Conveyed
Via Words...
1. 7%
2. 23%
3. 56%
Communication by the
Numbers
• 55% Body
Language
• 38% Tone of
Voice/Pace
Words
Tone/Pace
Body Language
• _7% Words
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Are You Listening?
• They’re NOT listening
• They ARE listening
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Listening – filling in the gaps
• A person generally speaks 125 words per
minute but can process over 400 words
per minute.
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Keys for Active Listening
• STOP
• LOOK
• LISTEN
• ASK
• PARAPHRASE
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Listening
• Effective listening can help improve your
diagnosis of patient’s problems
• Can help you understand the psychosocial
issues affecting their health
• Can potentially help you avoid a lawsuit
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Divergent Frames of
Reference
• Different for physician and patient
• Physician-think about serum creatinine
level
• Patient-how does this affect my tennis
game?
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The most important thing in communication
is hearing what isn’t being said.
Anonymous
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Difficult Conversations
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Harvard Negotiation Project
• Doug Stone – Harvard Negotiation Project
• Listen for these three layers in patients’
conversations
• Gain deeper insight into dynamics of the
difficulty as well as clues to solution.
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Difficult Conversations
- The Three Layers -
The Facts
The Feelings
The Identity Issues
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Difficult Conversations
- The Three Layers -
• Layer 1: The Facts
– Who did what?
– When?
– What happened?
• Things are rarely what they seem
• Don’t assume
• Don’t stop here
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Difficult Conversations
- The Three Layers -
• Layer 2 – The Feelings
– What Emotions are driving behavior?
– Worries/Fears
– Hopes
– How do they feel about what happened?
• May threaten identity
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Difficult Conversations
- The Three Layers -
• Layer 3 – The Identity
– What does this say about me?
– What is at stake?
– How will I see myself? How will they see me?
• “What does this mean to you?”
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Difficult Conversations
- The Three Layers -
• Recognize, Acknowledge, Accept
– Benefits
• Build a Connection
• Make Better, More Informed Choices
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
The “FEARED” structure
for Difficult Conversations
•
•
•
•
•
•
Facts
Empathy
Anger
Recite Back
Extended Family
Document
Woods, James OB/GYN News, August 2002
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
FEARED Model
• Facts-provide facts of case, based on chart and
hospital course; establish foundation
• Empathy-express empathy; acknowledge that
caregivers will try to understand what went
wrong and help family deal with issues they face
• Anger- ask whether patient feels angry, and if
so, where those feelings are directed.
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
FEARED Model
• Recite – have patient recite back clinician’s
explanation; ensure understanding of medical
issues involved
• Extended Family-directly address any present
• Document – conversation including FEARED
points
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Discussing Prognosis
• Back and Arnold, Journal of Clinical Oncology. Vol. 24,
Number 25 Sept.1 2006
– “How Much Do You Want to Know? Talking to Patients Who Are
Prepared for Explicit Information”
• Most common strategies physicians use in the
discussing prognosis
– Realism
– Optimism
– Avoidance
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Discussing Prognosis
• A quantitative study concluded that physicians can
provide the right amount of information for a particular
patient only after eliciting that patient’s goals and values.
• “How much do you want to know about the likely course
of this disease?”
• Based on patient-centered communication
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Discussing Prognosis
• More complex than other communication tasks, such as
giving bad news.
• Requires synthesis of communication skills and
biomedical content knowledge.
• Comfort with fundamental communication skills,
detecting emotions, responding empathetically and
eliciting patient understanding. Also assumes physician
is prepared to discuss relevant biomedical literature.
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Discussing Prognosis
• Some patients will say they want a lot of information, but
their body language contradicts this.
• hesitating, looking down, shifting in seat
• facial expression indicating distress
• “I notice you are hesitating..are you having other
thoughts about this? Or, “Is this a difficult issue for
you to talk about?”
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
For patients who want
information
• Negotiate the Content of the Discussion
– “How much do you want to know about the likely course of this
illness?
– “Some people want lots of details, some want a big picture and
others prefer I talk to their family. What would be best for you?”
• Provide the Information
• Acknowledge the Patient’s and Families’
Reaction to the News Explicitly
• Check for Understanding
– “Tell me what you are taking away from this discussion.”
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Demonstrate Support
Active Listening
C-A-R-E
• Concentrate
• Acknowledge
• Rephrase
• Empathize
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Giving Feedback
•
•
•
•
•
Inquire
Describe behavior you perceive
Express feeling in response to behavior
Specify impact of behavior
Ask to consider consequences; “Can
we agree to work together on this?”
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Demonstrating Support
Rephrasing
• Shows you have been listening
• A chance to be sure you heard and
understood correctly
• Helps eliminate confusion
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Empathizing
• Demonstrates understanding of person’s
situation
• Listening for content, intent and emotion
• Watching for verbal and non-verbal
• CAREful Listening
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“I” Statements
• Self-assertion
• Position on subject under discussion
• Non-judgmental language
• Focus on facts
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Reframing
• Take a second look
• Be open to different perspectives and
possibilities
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Six Steps for
Resolving Conflict
Between Others
1. State reason for meeting & ground
rules
2. Explore the conflict – Hear both sides
3. Express needs, hopes, concerns
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Six Steps for
Resolving Conflict
4. Generate ideas toward solution
5. Select a solution
6. Decide on follow up steps
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Points to Ponder
– What do I usually do and say in an
emotionally tense interaction?
– What is working well and what gets in my
way?
– How do I want to be next time?
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Points to Ponder
– How could I better engage patients in their
healing process?
– What specifically should I do differently or
stop doing?
– What WILL I do? How will I know I’m
progressing?
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Thank You!
•
•
•
•
•
Ann Grana
AMG Group
ann@amgccc.com
www.amgccc.com
314-541-2220
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Taking Your EHR to the
Next Level
Joe Wilmot
Regional Sales Consultant
GBS Corp
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Healthcare is Broken!
• Healthcare Represents 17.9% of
our Economy
• 2.5 Trillion in 2010
• Life Expectancy has lowered from
1.5 years above average in 1960 to
1 year below average in 2010
• USA first in Expenditure but 37th in Performance
• Institute of Medicine Advocates the Need to Adopt and
Evolve
• Healthcare Providers must embrace Data-Driven holistic
approach to Care and Population Health
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Can EHR Make The Difference?
EHR can make the difference by using Technology to
take it to the Next Level!
•
•
•
•
Patient Intake
Patient Education
Patient Reminders
Patient Satisfaction
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Patient Intake – Patient Portal
• Patient Friendly Input
Form Design
• Intelligent form
progression
• Track skipped questions
• Integrated with EHR
• HIPAA secure and
compliant
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Patient Intake – Pen Technology
• Ease of Use – Patient Friendly
• Eases Adoption of EHR
• Flexibility in Form Design
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Patient Intake - Kiosk
• Check-In
• Update Patient
Demographics
• Update Clinical History
• Credit Card Co-Pay /
Account Payment
• Patient Picture
• Receipt Printer
• Eligibility Checking
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Patient Education – Why it Doesn’t Work
• Face-to-Face discussions are the end of an
encounter is typically a waste of time!
• Patients cannot digest all the information
• Too much information at one time
• May not be engaged into listening
• Concerns about condition
• Most important questions come up
after the patient leaves
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Patient Education Fundamentals
• Patient needs to leave with something in hand
• Patient Education needs to include
• Reason for Visit
• Details Necessary to understand Care Plan
• What Medications are prescribed and why
• Homework Sheets
• Home Treatments
• Precautions
• Pertinent External Resources – Web
sites/Books/Videos
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Patient Education Fundamentals
• Providers should devote
time to Patient Education
• Inform patients about their
conditions with clear
explanations
• How to prevent, treat and
manage condition
• Listen compassionately
• Acknowledge patient’s
predicaments with
empathy and caring
statements
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Patient Education with EHR
• Many electronic Patient Education
Libraries to choose from
• What is integrated with your EHR?
• Linked to Patient Care Plan
• Linked to Patient’s own Clinical
Data
• Specific Instructions that relate to
Patient’s Condition
• Automatically note in patient’s chart that Patient Education
was provided
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Enhanced Patient Education with
EHR
• 3-D Modeling
• Track Patient Interaction
to Document
understanding and
informed consent
• Automatically send context- aware patient education and
summary sheets via patient’s email/portal
• Customized to specific components of the patient’s
treatment – Surgery, Procedures, Research, Outcomes
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Enhanced Patient Education with
EHR
• Push to Patient Portal
• Prompt when opened by the
patient
• Use Secure email to request
additional materials
• Multiple Language Options
• Searchable Patient Education
Library on your Patient Portal
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Patient Education Benefits
• Decreased
Patient Anxiety
• Increase patient
understanding
• Improve patient
compliance
• Improved
outcomes
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Why are Patient Reminders Important?
•
•
•
•
Improves patient visit frequency
Decreases No-Shows
Preventative Care Reputation
Improve Patient Care
Experience
• Improves patient visit quality
and satisfaction levels
• Facilitates Meaningful Use,
PCMH and ACO Compliance
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Not All Patients Are the Same
Your patients may need different levels of Patient
Reminders
• Low Risk – Patient need little oversight or follow-up
• Medium Risk – Patient with Chronic Conditions
need Care management
• High Risk – Require Specific Care coordination to
prevent costly events such as hospitalization
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
EHR Patient Reminder Technology
Patient Data can be
made Actionable
• Identify gaps in care
• Proactive Reminders –
Appointment / Health
Monitor Screening /
Medication Refills
• Intelligent Rules
Engine to filter and
create reminders
• Multiple Contact Methods
• Patient specific Text Messaging defaults
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
EHR Patient Reminder Technology
• Push data to your
Patient Portal
• Use Secure
Messaging to interact
and confirm
• Create alerts with
reminder event is not
met
• Clear when
appointment is set
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
EHR Patient Reminder Technology
• Use
Dashboards
to monitor
compliance
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EHR Patient Reminder Technology
• Potential to
enhance
revenue is
real!
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Patient Satisfaction – Why is it Important?
• Improve Revenue
• Measure of Quality Care
• Attract and Retain
Patients
• Patients that are satisfied
stick with their providers
• More likely to refer to
friends and family
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Patient Satisfaction – Why is it Difficult?
• Making everyone happy is a
losing battle
• Doctor recommendations can
collide with patient
expectations
• Can cause over-prescribing
and over-testing to keep
patient happy
• Effectively communicating the
rationale so patients
understand
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Patient Satisfaction – Don’t Forget About
Social Media!
• Your Practice and the Internet
• Google your Practice and Providers
• Build and Protect Your Reputation
• Automated Social Media Posts
• Search Engine Optimization
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Patient Satisfaction – What are the benefits?
• Decreased Patient Anxiety
• Increased Patient
Understanding
• Improved Patient Compliance
• Outcomes Data
• Improved Provider-Patient
Communication
• Alerts Practice/Provider of
pending issues-concerns
• Improves referrals
• Patient retention
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Using EHR for Patient Satisfaction
• EHR Technology
• Patient Portal – Pushed
after clinical encounter
• Automated compliance
tracking
• 3rd Party Add-Ons
• Download appointments
• Surveys pushed to
patients
• Compliance tracked and
follow-up by service
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Using EHR for Patient Satisfaction
• Use Outcomes to track
overall compliance
• Alert of issues/concerns
with specific workflow
• Alert of issues/concerns
with staff and providers
• Use as a tool to adjust
and improve
• Know how & where to
improve your practice!
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Patient Satisfaction – Make it Work!
• Make sure everyone is one the
same page
• Listen to employees – present
ideas
• Collaborate at all levels – Check-In
/ Nurse / Provider / Check-Out /
Administration
• Small things matter
• Make the patient comfortable
• Free wireless in waiting room
• Use technology to reach out to
patient
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220
Mike Spencer
Regional Sales Consultant
GBS Corp
(314) 517-5054 (Cell)
(314) 966-4692 (Office)
mikesp@gbscorp.com
Work Smarter • LeagueOfHealthcareExperts.com • 314-541-2220