Advice and Commentary on the World of Professional Consulting

Physicians, Shouldering the Brunt, Carry On

By George W. Chapman, MBA

I have worked with physicians, as an administrator or consultant, in every type of healthcare setting including: primary care, specialty care, community and regional hospitals, health centers, clinics, for profit, not for profit, urban and rural for my entire career. At no time have I been more impressed by their professionalism, fortitude, resiliency, adaptability and yes, sanity, as I am now.

U.S. Pacific Fleet via Compfight

Unbeknownst to most people, your physician has managed to carry on and provide you with excellent care while shouldering the brunt of the most radical and comprehensive (but well intentioned) changes in their industry since Medicare. Despite the virtual healthcare war being waged in congress and all the uncertainty in the industry it creates, your physician continues to provide excellent care and remains your best advocate.      

The Patient Protection and Affordable Care Act of 2010, or ACA, set into motion dramatic, pervasive and unproven changes in how healthcare will be organized, delivered and reimbursed. It will impact all of us, regardless of age or insurance. But most consumers would never know that because the press and politicians have focused almost exclusively on the exchanges.

The exchanges are a relatively small component of the entire Act. Of the 20 million people who receive their insurance because of the ACA, 7 million are on expanded Medicaid which leaves only 13 million out of 320 million of us (4%) purchasing individual insurance from a commercial insurance company on the exchange. The obsession with the premiums and carriers offering insurance on the exchanges has totally overshadowed the rest of the ACA which impacts us ALL. There is much more at stake for physicians, hospitals, payers and all 320 million of us than just the exchanges.  Some background is in order.

Prior to the ACA, there was general consensus among the “players” (physicians, hospitals, insurers, government, employers) that our fragmented and super expensive US healthcare system had to change. Healthcare costs us over $3.2 trillion annually or about $10,000 per person which is more than double the per capita costs in Germany, Sweden, Canada, France, Australia and Japan. The ACA was developed with input from all the players. But because everyone had vested interests to protect, what we got was compromise, not a perfect solution, and we all know how hard it is to keep everyone happy. So what happened?

The ACA became a political football and critics quickly dubbed it “ObamaCare”. When Medicare was passed into law in 1965, it wasn’t dubbed “JohnsonCare”. We all know the more political anything becomes, the more irrational, divisive, emotional and uncivil the discourse. Facts are twisted or spun if not totally ignored and the search for blame and the development of straw man arguments begin. There is far more to the ACA, and its impact on physicians in particular, than meets the public eye.    

Hundreds of billions have been invested by the players in preparation for the changes, agreed upon in principle, to improve affordability, access and quality. “Triple Aim” is the mantra of system reform: improve overall health, enhance the experience of receiving care and lower costs. Six years into the ACA, just about every horse is out of the barn.

Repealing and replacing the ACA would be like canceling an important experiment before the results were in. The ACA has been rolled out in phases and will continue to be rolled out until 2022. We are half way. Because of all that has been invested so far, none of the critical players in healthcare (physicians, hospitals, insurers), is actively lobbying Congress to kill the ACA. Too much money has been invested in complying with the ACA, especially by physicians and hospitals. Our healthcare system will take time to “fix” and starting over or introducing new legislation half way through the 12 year ACA experiment makes no sense.

As politicians, pundits and analysts pontificate, and government agencies regulate, and “big insurance” and “big pharma” bloviate about decreased profits, physicians have quietly scrambled to comply with the myriad of mandates and changes, all the while managing to take care of us. In order to get paid, or not be penalized, physicians have had to (for better or worse): master one or more electronic medical records systems; morph into “population managers”; transition from fee for service reimbursement to fee for quality or outcome; learn new and ever changing procedural and diagnostic coding; adhere to quality metrics and incentives that differ by third party payer; forfeit their autonomy by working with “care management teams”; affiliate with the alphabet soup of “health systems” out there such as ACOs (Accountable Care Organizations) and CINs (Clinically Integrated Networks); compete with retail clinics; incorporate telemedicine and on line access; and much more.

Factor in declining revenue and increasing expenses on top of all this and you can appreciate what physicians have had to deal with over the past few years. While physicians aren’t happy with every aspect of the ACA, most agree things had to change.

Despite all the regulations, mandates, confusion, and even uncertainty as to how they will eventually be paid, physicians do remarkably well according to their patients. A Harris poll from about a year ago revealed that 88% of those surveyed report they were “satisfied” with their most recent doctor visit. The aspects of a visit to the doctor’s office considered to be “very important” are: doctor’s training and expertise: 83%; doctor’s ability to access overall medical history: 65%; time spent with doctor: 58%; ease of making an appointment: 49%; efficient and simple billing process: 45%; ability to communicate with the doctor by phone or email: 44%; time spent waiting: 43%; convenience of office location: 40%; minimized paperwork 32%; office appearance: 31%.

To my knowledge, no other profession has had to endure more changes or more attacks on their autonomy than that of physician. Yet, they are exhibiting an uncanny ability to block all the “distractions” around them and focus on us in the exam room.

Physicians are a tough breed. They aren’t looking for our sympathy. Physicians are looking for us to be compliant and to take responsibility for our health. They want us to be active partners in our healthcare. Their success will depend on our success in the new reimbursement system.

Finally, I think a little understanding and appreciation are in order. Hopefully, you now have a little better idea of the conditions under which they are working. So… if your physician is running a bit behind or seems to rarely look up from his/her lap top, cut him/her some slack. Consider how they must carry on while shouldering the brunt of change.

Healthcare In A Minute - October 2016






by George Chapman, GW Chapman Consulting

Hospital ratings. The recent five star ratings of hospitals by Medicare raised the issue of whether large teaching hospitals got a fair shake because the survey upon which the ratings were based (Hospital Consumer Assessment of Healthcare Providers and Systems) did not account for patient acuity. Large teaching hospitals treat more trauma and often care for difficult patients transferred to them by surrounding rural and suburban hospitals.   A study published in the Journal of General Internal Medicine looked at online hospital reviews by consumers on Yelp. About 25% of the almost 3,800 hospitals in the Medicare survey also had ratings on Yelp. The correlation between the Medicare rating received by a hospital and the Yelp reviews was very strong. Yelp reviewers reported on staff quality and compassion, access, convenience, bedside manner, cost, billing, scheduling, treatment of family and visitors. Researchers found that consumers are more savvy than the industry thinks. Hospitals that performed better on both outcome and processes enjoyed greater market share and growth. Word gets around and patients seek care where it’s the best.

Telemedicine.   Many argue telemedicine will never be as effective as a real face to face encounter between patient and provider. So far, the technology has proven effective in many scenarios such as: the patient is incapacitated (sick, injured, contagious); foul weather; transportation is unavailable (commercial or care giver); patient just needs remote monitoring;  patient needs encouragement or compliance pep talk; patient needs medicine checked; patient has mental issues and acts out; patient can’t leave work; on call provider can refer to video visit.

RomneyCare update.  Industry observers keep an eye on what is happening In Massachusetts because it is consider the harbinger of things to come under the Affordable Care Act. The Massachusetts Center for Health Information  reported that costs in 2015 were $8,424 per capita which is an increase of 3.9% over 2014. The benchmark or target was an aggressive 3.6%. (Everyone in Massachusetts has insurance.)  As with the rest of the nation, drug costs were responsible for most of the cost “overrun”, accounting for a third of all costs. Larger, more efficient healthcare systems are putting a lot of financial pressure on smaller community hospitals and rural systems.

2016 election.  Both candidates agree drug companies seemingly raise prices arbitrarily and something needs to be done.  Trump would allow Medicare/Medicaid and commercial payers to purchase drugs from countries like Canada. Clinton would appoint a federal watchdog to monitor price increases and limit the amount of income consumers would have to spend out of pocket on drugs. But controlling the pharmaceutical industry, let alone prices, will not be easy unless the revolving door between the FDA and the drug manufacturers is controlled. The FDA has data on how many of its former employees now work as consultants or lobbyists to the pharmaceutical industry but has not released such data.

National spending.  In 2014, we spent $9,523 per capita. Still the most by far of any developed country. At $3 trillion, healthcare was 17.5% of our GDP in 2014. (it is currently trending at 18%.) Medicare and Medicaid accounted for 36% of spending. Commercial insurance accounted for 33% and out of pocket another 11%. The remaining 20% is VA, federal employees, Public Health Service and other federal programs.

Specialty rankings.  According to a study of online physician reviews published in Becker’s Hospital Review, consumers report the highest satisfaction levels with neuromuscular specialists, thoracic surgeons, podiatrists, plastic surgeons and colorectal surgeons. The lowest ranking were with: psychiatrists, preventive medicine specialists, pain specialists, emergency physicians and neurologists.

Physicians refusing care.  A debate over how much autonomy a physician should have when he/she has a conscientious objection to providing a service like abortion, birth control, unnecessary testing and assisted suicide is published in the Journal of Bioethics.  Those who argue a physician does NOT have the right to refuse care feel access to care, especially when there are few if any alternatives, must override a physician’s personal beliefs. Those who argue a physician DOES have the right to refuse care argue they are entitled to have values like everyone else. Sweden and France bar physicians from refusing any legal service and can suspend or revoke a practitioner’s license. The US, Canada and the UK have historically allowed the refusal of services based on conscientious objection. Most physicians who will not provide certain services due to moral objections will be happy to refer their patients to another provider without disrupting the overall relationship between them.

Watch your scale.   The good news, according to a study by a Cornell professor published in the New England Journal of Medicine, is your weight might be at an annual low…. right now. The bad news is that, thanks to the upcoming holidays, you will gain weight and a lot of the gain will be permanent if you don’t pay attention. Weight gain typically starts 10 days before the holiday season and peaks around New Year. Because the study participants were aware they were in a weight study, the professor believes the weight gains were probably artificially low to moderate and that weight gain in the general public is worse. Other studies have found that after 30, most of us gain two pounds of permanent weight every holiday season.

CNY Smokeout.  3K fun run to promote giving up tobacco products and creating healthy lifestyles. Sunday November 6, 2016. Onondaga Lake park. 8 am registration.  $20 entry fee. 727-3074 for more information.

The Importance Of Member Spotlights

Something that the Professional Consultants Association of Central New York does that you don't see a lot of other organizations doing it allowing time for a member to do what we call a 5 to 10 minute spotlight on their business and accomplishments. We tend to believe that it's important not only for the rest of our members to know that we have such accomplished participants in the organization, but it gives the members themselves a chance to get up in front of a friendly group of cohorts and present themselves live.

DannyChawan002What most organizations don't pay attention to is that there are a lot of members who like to stay in the background and just come to watch, but never to participate. As consultants, our belief is that everybody needs to be practiced in the art of presenting to others. We also understand some people are a bit more shy than others, but if you can't talk in front of people you're familiar with you're not going to be a very good consultant long term.

At our first meeting of the season, Danny Chawan of  Srim Enterprises talked about his career as a PhD food scientist; at least that's what I call him. Danny has multiple patents for his discoveries and creations, and has worked with multiple companies across the world in helping them to figure out how to mass produce their products. He is also kind of a local celebrity, having them and both the local regular and business newspaper many times because a lot of the work he does is in the basement of his house, which is a veritable laboratory.

Danny is also a longtime member of the PCA board, butt it's probably been a long time since we got to talk about himself in front of a lot of people. That's why we were happy that he spoke to us, and I know that with the questions a few people asked all of us were illuminated and fascinated by some of his adventures. Below is a small sample of a blog post he once wrote that helps illuminate what he does:

The Things That Affect Taste And Quality

I am a food scientist, a term that may be misunderstood by a lot of people. What I do is figure out how companies can mass produce their food items based on original formulas and recipes so that those products will taste like expected later on.

One might not know how hard it is to get something like this right, but all you have to do is think about making something as simple as cornbread and mixing together two boxes of ingredients at once instead of just one. You might initially believe that if you’re going to do this that all you have to do is double everything. However, you find that when you bake the cornbread, it’s not coming out quite as you thought it might. Maybe the middle doesn’t cook all that well or the outside gets burned, or maybe it doesn’t spread the way you expected it to in the pan.

In that small experiment, you realize that you have to change many things, from how long you bake to what temperature to even how much of the other ingredients you should put into your cornbread mix. Do you put more or less milk in? What about the eggs?

If things can go wrong with something that simple, imagine what it’s like when you’re looking to make thousands, if not millions, of a product at one time in a factory. The chemistry alone can be daunting. It’s not just ingredients or temperature at a certain point. It’s the type of oven or vat you’re cooking in, how you’re putting your product into its packaging, how long it should cook or cool, the order of ingredients, the power of spices… so many things. Many times the corrections are minor, but it could take weeks of testing to figure it out. Other times the corrections are major and costly; there are a lot of great products that never make it to market because it would cost too much to create them.

This is one reason why homemade products, or products made locally, cost so much more than products from large companies. Local products are made in smaller quantities to retain their quality, while larger companies might end up cutting some corners to get out what they do. Don’t take my word for it; make some rice krispie treats, then go out and buy a box of them, and taste them yourself. I believe you’ll understand where I’m coming from.

I tend to believe that more organizations should think about having some of their members present themselves to the group, whether it's a sort of Trade Organization or Professional Organization. After all, when groups of people get together with some clarity, not only will they have good things but sometimes they can ask questions that would benefit everybody. It's also nice to know that there are a number of Professionals in the room who are ready to celebrate as well as assist whenever possible.

This is one of the major benefits of being a member of PCA; it's open to every one of our consultants; all they have to do is ask or wait to be asked. :-)

Healthcare In A Minute - August 2016






by George Chapman, GW Chapman Consulting

Hospital rankings released.   After months of delay due to concerns about the methodology used, CMS released the results of its hospital quality rankings. 4,600 hospitals received from one to five stars based on 64 quality measures like post-surgical infection rates, average waiting time in the emergency department, readmission to the hospital after a heart attack, use of CT and MRIs, complications after hip surgery, etc.  102 hospitals (2%) earned ***** stars. 934 (20%) earned ****stars. 1,770 (38%) earned *** stars. 723 (16%) earned ** stars. 133 (3%) earned * star. 937 hospitals (20%) received no ranking due to insufficient data. NYS had the most one star hospitals with 35 of the 133. 33 were downstate. Faxton-St. Luke in Utica and SUNY Health Science Center in Syracuse were the two upstate hospitals getting a single star. Many  believe the rankings were biased against teaching hospitals which typically treat more trauma, transfers from other hospitals and the more complex cases.  Go to “CMS Hospital Compare” on line to check a hospital’s ranking.

Cancer survivors increasing.   The number of cancer survivors will increase by 11 million over the next two decades according to the National Cancer Institute. Their numbers will increase from the current 15 million to over 26 million.   Almost 75% of the survivors will be over 65 by 2040.  

Text messaging your physician.  CMS is working on guidelines for text messaging. The availability of better and secure text messaging technology caused CMS to  reconsider its ban on text messaging which has been in force since 2011.  Various studies indicate text messaging can accelerate care, boost communications between patients and their providers and streamline patient activity. A recent study of women diagnosed with breast cancer found a much higher level of satisfaction with both treatment plans and their decision making among women who used some means of electronic communication with their physician.

Healthcare to be 20% of GDP. According to Office of the Actuary under CMS, healthcare expenditures will grow 5.8% a year between now and 2025. That is about 1.3% faster than the rest of the economy, which could make healthcare 20% of the GDP by 2025. We spent $3.2 TRILLION last year on healthcare. The Affordable Care Act has been credited with keeping annual increase to “moderate levels” compared to the 8% growth rate in the two decades prior to the ACA. Price inflation accounted for less than 1% of the increase in expenditures. We continue to spend far more, per capita or percentage of  GDP,  than any other country.

Curbing fraud.   Penalties will soon double.  The minimum penalty for EACH false claim submitted to CMS will double from the current $5,500 to nearly $11,000. The maximum penalty per false claim would increase to over $21,000.  There are typically thousands of false claims in a particular case meaning penalties reach into the million and sometimes billions.  Whistleblowers receive a cut of the monies recovered. Many feel the higher penalties may invoke the constitutionality of the fines as a defense. The eight amendment prohibits excessive fines. However, most cases are settled on damages or the government’s actual losses versus penalties.

Trump’s plan.  Republicans have tried to repeal the ACA nearly 50 times. Mr. Trump has vowed to repeal it if elected. According to the non-partisan Center for Health and Economy, Trump’s plan would upend most of the recent reforms under the ACA.  18 million Americans would lose their insurance due to elimination of tax credits and Medicaid expansion.  Premiums would decrease across all plan categories (bronze, silver, platinum) by removing actuarial rating and deductible restrictions and the individual mandate.  Medical productivity would increase 2% due to a shift from employer sponsored plans to individual plans.  More cost sharing would result in a more price conscious consumer.  Provider access would increase 11% based on the assumption that new low benefit, low premium  catastrophic plans would offer a wider network of providers.  The federal deficit would decrease $583 billion over the next decade due to provisions directly related to removing the standard benefit packages under the ACA.

Feds to Increase value of primary care.   In a continuing effort to make primary care more appealing to medical students and to reward those already practicing, Medicare will increase payments for lnternal Medicine, Family Medicine, Ob/GYN, Pediatrics, Geriatrics and mental health by $900 million next year. Most of the increase will come at the expense of specialists. Commercial insurers tend to follow Medicare’s lead on how physicians and hospitals are paid.      

Random health facts.  Lack of exercise causes as many deaths as smoking.  Eating out regularly at restaurants doubles your risk of obesity. Laughing 100 times equals 15  minutes of exercising on a stationary bike. 30% of cancer can be prevented by avoiding tobacco, limiting alcohol and exercising regularly. Averaging less than seven hours of sleep a night reduced your life expectancy. Just one soda a day increases your chances of type 2 diabetes by 22%. 

The Art Of Persuasion - James McEntire

In April, James McEntire came to talk to us about The Art of Persuasion. He spoke to us about 4 particular things that stood out and garnered some conversation amongst the members.




The first was the Law of Reciprocation. The basic principle behind this one is that all of us in business should always look to see what we can do for others before thinking about what they can do for us or how we can work with them. This in turn makes people feel they owe you something, and that can prove to be very beneficial to your business later on. Your motives need to be genuine, without the expectation of people owing you on the back end; thus, it takes a lot of courage and a good heart.

The second followed up on the first, which he called the Saddle of Obligation. In this case, the concept goes deeper because someone might need help or a favor that you help them with that has nothing to do with business whatsoever. What happens is that most people feel obligated to find ways to help you, even if it's just recommending you to other people they might know who can use what you have to offer.

The third flows with the first two, and doesn't fall into a tidy phrase. His recommendation was that when you meet people at networking events, try to figure out how you can help them. This follows up on a principle Zig Ziglar stated which goes "If you want to achieve your goals, help others achieve theirs."

I felt this one personally because I remembered when I was first in consulting I couldn't get anyone to talk to me, even though none of them were in my field of expertise. Afterwards, when I got my bearings, I made it my mission to always help by giving advice when asked by anyone trying to become independent, even if they could potentially be competitors.

The final piece was to work on being an authority or expert in your field. That sounds pretty easy and yet many people don't figure out how to get that done. We all find it hard to talk about ourselves, to the extent that we might minimize just how good we actually are.

In essence, what's our unique proposition; what sets us apart from others who do what we do? As Peggy Klaus said in the book "Brag", we have to learn how to toot our own horn because we can't always rely on others to do it for us.

These are all good principles for anyone who's self employed or works as a consultant.