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The Fickenscher Files, Vol. 16
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Quote Of The Week

"So, thinking that she was a friend - and I have helped many friends - I now know
that she wasn't the friend that I thought she was. But it was just a friendship
relationship...That being said, obviously, this is cause for reassessment."

Herman Cain, Republican candidate for President of the United States in a press
conference on the latest allegations of impropriety.

Consulo Indicium

Information for your Consideration...

Where Will The Supremes Focus - On The Individual Mandate or Medicaid Expansion?
The Supremes announced last week that they are not only considering the challenges
from the states on the individual mandate but also will be reviewing the law's sweeping
expansion of Medicaid. The issue is being taken up primarily because it lies at
the intersection of the sometimes rocky relationship between the federal government
and the states. The review will most likely focus on the amount of leverage the
federal government is applying to the states and whether or not it is an appropriate
point of leverage. The decision will probably be even more important than the decision
related to the individual mandate because of the implications it has on federal-state
fiscal relations. So, keep an eye on it...it will be an interesting point to watch...

As If Texting Wasn't Enough? - In our world of plenty, there are lots of things
that we could live without. So, I was a bit curious when I read that the London
Science Museum recently conducted a survey of 3,000 adults, asking them to name
what they couldn't live without. Some of the items on the list were to be expected.
For example, flushing toilets, showers and fresh vegetables were near the top of
the list. But these solid "must have's" were outranked by a new competitor in the
world of must have things in life - Facebook, which ranked fifth among the choices.
In a separate survey, 55% of cell phone owners aged 24 and younger now prefer texting
to voice conversations. In fact, the younger generation averages 110 texts per day.
I thought I was keeping up but clearly, I'm way behind. And, to top it off, I only
check my Facebook page periodically...

American Smoking Habits - The CDC recently reported that the rate of smoking in
the USA is back down to 19%. It was down there in 2009 but bumped up in 2010, primarily
because of younger smokers taking up the habit. The USA is continuing to make progress
in efforts to reduce the number of smokers but the extent of the decline is diminishing.
Back when Surgeon General Terry Luther, MD issued his report on the health ramifications
of smoking, the rate topped 40% in the USA. Over the last three years or so, we
seem to be hovering around the 20% level. With both a father and a brother who died
from smoking induced lung cancer, I'm one of those strident individuals who feels
we need to continue pushing for further reductions. The stated goal is to reach
12% of the population smoking by 2020 but, at the current rate, we will not make
it. And, curbs do work. Utah and California which have the toughest state laws
related to smoking have a 1 in 10 ratio of smokers (about 10%) versus the smoker-friendly
states like Ohio and Kentucky which have rates closer to one in four or, about 25%.
If we really wanted to impact the cost of healthcare, I've got a suggestion on where
to start...

Berwick Resigns - As expected, Don Berwick, MD submitted his resignation as the
head of the Centers for Medicare and Medicaid Services (CMS). It was an unfortunate
forced resignation because of the way in which President Obama appointed Berwick,
as a recess appointment. His re-nomination would have been blocked by any number
of conservative legislators who are generally opposed the reforms set in place
by the Accountable Care Act. In Berwick's place, President Obama will nominate Marilyn
B. Tavenner, RN, who served as Dr. Berwick's deputy. Ms. Tavenner previously served
as the secretary of Virginia's Department of Health and Human Resources under former
Governor Tim Kaine. I must say that Don Berwick did an outstanding job from my perspective.
We could not have asked for a better leader of one of the most important programs
in healthcare than Don Berwick. His tenure will be noted for its creativity and
energy in challenging those of the healthcare work to think differently. As a point
of personal perspective, I believe it is very unfortunate that politics got in the
way of his tenure. Let's hope that Ms. Tavenner can continue the momentum that Dr.
Berwick created.

A New Medicare Cost Control Approach Gains Some Momentum - While the Supercommittee
failed in its efforts to come up with the $1.2 trillion dollar savings to reduce
the federal deficit, it did hear arguments for structural changes to Medicare reform
that are gaining some bipartisan momentum on Capitol Hill. In testimony before the
committee, proposals were put forward to alter Medicare such that the open-ended
financial commitment to the program would be eliminated. Specifically, the idea
is that Medicare beneficiaries would be offered a fixed amount of money to buy
coverage from competing private plans. Those plans would be tightly regulated by
the government related to their cost structure and benefits offerings. It's a plan
that appeals to the Republicans and some Democrats who believe that a carefully
designed plan with the right protections in place for beneficiaries may be feasible.
While there is some bi-partisan support for the plan other leading Democrats are
concerned that the approach represents a cost shift to Medicare beneficiaries.
We should expect that this idea will gain some momentum in the coming months. As
I have said repeatedly, Medicare is in the center of the target where changes will
occur because of the looming federal deficit. The approach is an interesting idea.
The devil - obviously - is in the details...

Use Of Retail Medical Clinics Growing - In a new study by Rand Corporation [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108882491881&s=6409&e=001MjbMnRnimS0ch_aoSycBX46RoZSFumcbBIrrWgCUU6rZhhEbxMQeCua-QRvy-2PUX5mdVztrL3YLj6G4WBw8-JEA7aFsqSpvWicTy8H3XriLfDDWkQxKNir1K6yVn9FAvY_LQ_wBMP78RVniViyPFzFHSliEVVzKjq0FiE-Pj2M=],
medical care provided at retail clinics (e.g. Minute Clinic, Walgreens, Walmart,
etc.) is 30 - 40% less expensive than similar care provided in a physician's office
and, 80% cheaper than those services provided in an emergency room. In support of
the Rand Study, a report in American Journal of Managed Care which reviewed the
retail clinic use patterns of more than 13 million who held private Aetna health
insurance plans. The results showed that retail clinic use for conditions such
as ear infections, flu, urinary-tract infections, and allergies increased tenfold
between 2007 and 2009. So, the increased use pattern seems clear. However, what
remains unclear is what the impact of these clinics will have on overall costs.
Many experts believe they will provide a dent in the continuing escalation of healthcare
costs. The retail clinics are similar to the "focused factories" that Regina Herzlinger,
Ph.D. of Harvard describes as an approach toward reducing the overall costs of healthcare.
Essentially, the retail clinics limit services to the top 20 - 30 most common diagnostic
problems that confront the primary care physician such as flu, ear infections and
bronchitis. And, as importantly, the service is good. It's "in and out" without
all the fuss, waiting and other impediments that are prevalent throughout the traditional
healthcare system. I've been predicting for the last decade that we would see the
increased use of and demand for retail clinic services. The new healthcare reform
legislation is accelerating the phenomenon. In fact, the retail clinics are beginning
to look further upstream in providing services. Wal-Mart has expressed interesting
in partnering with healthcare organizations to treat more complex problems such
as HIV, diabetes, arthritis, and clinical depression. Through the appropriate use
of protocols and guidelines, I believe it is entirely feasible to consider such
an approach for the delivery of quality healthcare services. In the end, the retail
clinic is a phenomenon that will only continue to expand and flourish. For those
of us who believe in a comprehensive, coordinated care model then, the question
is how can healthcare organizations and providers collaborate with the new organizations
that are evolving to provide these services?

A Thanksgiving Thought

Considering what we can do in a time of reflection...

While we in the United States have plenty - despite the recession and all that it
has brought to us - we are still the land of plenty. There are many vulnerable people
throughout the world who are facing much more difficult situations than us such
as the people in the drought-stricken Horn of Africa, who are mostly women and children.
Despite our debt crisis and the acrimony on Capitol Hill, I was pleased to learn
that Congress made the decision to maintain support for international programs
that provide emergency food assistance to those in need - on a bipartisan basis.
Earlier this year, the House had threatened to cut emergency food aid by 39%, which
would have eliminated food aid for over 13 million people. It seems like everytime
we turn around this is a new crisis, the famine in the Horn of Africa, flooding
in Pakistan and other conflicts and emergencies around the world. I encourage you
to check out World Food Program USA and support their initiatives. They are doing
masterful work in helping to support the hungry around the world. Also, you should
take the WFP USA hunger quiz [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108882491881&s=6409&e=001MjbMnRnimS0gX5b_T8hK0T_-2IeAvw-nNGgwrhfFkEvTHmuCP2IjQPZmaPKnVdh03ZyO-8LYHXqm86vtth0EbBgZbx94QP0Zk6kCFaV7OCsyW1arnOm2c4AcHKfJ_j9bzmuavvxGDd3WqqPmFSmrxaTDI6Vo2WFnDQkn8jzWt4m8qfdelYzQIg==]
and pass it along to your friends and neighbors. It will help you gain a better
understanding on the impact of global hunger.

The Transition to ICD-10 Gets Push Back From The Healthcare Community

The upcoming ICD-10 project deserves attention, but it's not another Y2K...

Several weeks ago in the Fickenscher Files [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108882491881&s=6409&e=001MjbMnRnimS0P89vRGpWJpQ0KdL95un_b_KcpcXkEPpEBZeETlUXCusRyhuJTDziGbBD2OpHI5SmqP-CStJ1XtySfIdz39kODztPRRg7-zXe-ZXF0auxcHy8qIPUbB4vKgCUeBQs07zkRDu2JVJJlzWrNbZYxvCwO9Jla5jL4NSU2uCZRJ6VvPBKXdRtSmP8zgs9rV9WbclU=],
I discussed how the upcoming deadline to upgrade back-office billing and diagnostic
codes may affect hospitals and physician practices. In less than two years, every
health care provider that receives payment from Medicare or Medicaid must convert
from the current billing code system to a new, much longer list of codes used by
most other developed countries - the ICD-10 coding system or, International Classification
of Diseases, 10th revision. The looming deadline to convert from ICD-9 to ICD-10
is sending waves of anxiety through the health care industry. If physicians and
hospitals miss the deadline, they will risk losing revenue - a prospect that has
many health care executives losing sleep. And, to top it off many physicians are
resisting the ICD-10 upgrade - a trend that has intensified in recent weeks.

Indeed, the American Medical Association (AMA) believes the project is distracting
the physician community who they feel should be focusing on treating patients. In
a move to stop the ICD-10 upgrade initiative, the AMA voted [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108882491881&s=6409&e=001MjbMnRnimS0qfOUAvqkjK5eR9X45NoR4AkgfYty3m2Uglm0cdxnTKV37qPmlSrF6mC2YAYRUC-FP_zmDVRMZeI0SXumNQxKpEOQ2j60wa54MihyP2KRxt5au9Dxi59PlxSkkhtkKF6S3k9OigUGNfIyeJm_xZuu7yPOXb7d3So-B5ax8Y-sK5hxoTrC9ldRWgG-HcxXxD04=]
on November 15th to "to work vigorously to stop implementation of ICD-10." AMA President
Peter W. Carmel, MD said that upgrading to ICD-10 "will create significant burdens
on the practice of medicine with no direct benefit to individual patient care."
Carmel and other critics also object to the project's timing. CMS expects everyone
to upgrade to the new codes by October 2013 - just as health systems and physician
practices will be hustling to adopt Electronic Health Records (EHRs) to meet CMS's
Meaningful Use guidelines. Physicians and health systems also face tight deadlines
to form Accountable Care Organizations (ACOs) over the next two years.

One of the primary arguments physician groups are making is that switching to ICD-10
will likely cost about 10 times more than CMS originally expected. For example,
for a small office with just three physicians it is estimated that the group will
have to spend about $83,000 to upgrade to ICD-10, according to a 2008 study cited
by the AMA's in their argument to delay implementation. Similarly, a large, 100-physican
practice would spend an estimated $2.7 million to convert to ICD-10, again, according
to the same study.

Chief Information Officers (CIOs) have also shared their concerns about ICD-10's
cost at the College of Healthcare Information Management Executives (CHIME) forum
last Fall. As an example, Carole McEwan noted that the SSM Health Care organization
transition to ICD-10 [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108882491881&s=6409&e=001MjbMnRnimS2v0Zw8rl28y2jecYP06JgIOrV6LoS1wd4FOE41C5a9dna184JatSC2SAOugDXRuwRX72BinV3NFojRMATfi1MVbM0kjkn2j8glrXtMQgkJIMCV5HZOjzVlEw2cVcIK0wlHdyfIBCzROXyDGxo63_kKgecjgn_-80p3T8REdA0Ou8FhG0Yvi5a5]
may require up to 110,000 hours of training for the 15-hospital health system. McEwan's
peers agreed the project was taking more time, money, and resources than they originally
thought. A recent KLAS Research report [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108882491881&s=6409&e=001MjbMnRnimS09gntt0JD3vxJBM2bK38TA6wVdefsmXsH-UUOMmlVUzZfvyH4mnM01947a0QYbN329Ngp9L6QCr_40VXkAFfKfmhO-OZ2I6gCkQKzWd5_asuYAQFufD6OhCjt4-bIOrkyPu3QIH2C1__yQceIx-0ei]
drew similar conclusions.

Some pundits predict ICD-10 could rattle the healthcare industry even more than
Y2K transition effort or the 2008 financial market meltdown. But, despite the looming
deadline, KLAS reports that that most organizations are only in the strategy/planning
phase of ICD-10 implementation. In fact, fewer than one in 10 healthcare providers
were on track to meet the October 2013 deadline, say KLAS analysts.

So, why is the transition to IDC-10 so complex? Part of the problem is that the
number of diagnostic and procedural codes will increase from 18,000 under ICD-9
to more than 155,000 under ICD-10. Moreover, billing analysts can't directly convert
old codes into new codes. For example, a fractured leg code must provide more detail
such as which leg, the location of the fracture, type of fracture, etc. Upgrading
to this level of detail isn't quick or easy. In addition, the World Health Organization
(WHO) created ICD-10 codes to track diagnoses and inpatient hospital procedures
and, not to bill patients. Unlike many other developed countries, the USA uses these
codes for both purposes, which adds to the project's complexity.

The end result, is that hospital executives and physicians who were hoping to postpone
ICD-10 now see a potential glimmer of light. Before upgrading to ICD-10, health
care providers must first switch the way they process their payments to the Health
Insurance Portability and Accountability Act (HIPAA) 5010 transaction standards
[http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108882491881&s=6409&e=001MjbMnRnimS2688lElGFJB3aMXp4WjmFu3RhpyQZMwH_2URQERQ2e1UDTKUOTh8Vd0LBgS6ncdJ2q147FMQSNuvQnX8opoUPZCZ6OAxb_7KwVPeeuvq2WdjrPwgCZrYRtdD309XmniFH_6tLEihFkC0dk_ufe_83w].
Given the rancor in the healthcare community, the original deadline of January 1,
2012 was extended by CMS for an additional 90 days to March 31, 2012. Given this
delay, CMS may also push back their ICD-10 deadline. We will be following the issue...

The Weekly Whisk

Musings from a foodie...

Just before Thanksgiving, I had a business trip to Salt Lake City. Now, perhaps
my bias were evident but, I was not thinking that Salt Lake would be a culinary
experience. Wow - was I surprised!! As my readers know, I travel far and wide -
having the opportunity to visit many different restaurants. I consider my trip to
Forage [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108882491881&s=6409&e=001MjbMnRnimS1QDg5dTKfyNHRv6Sb3V6xgAm0qng5-nE6YgOU7ONt-gP4Dsw820O7UchfHTeyet30lpn-GCTwpoffZPp9ZfBFgcbRL-srcrvl0plblrQdafEFfRwArPS0B]
[*****] to be one of the most interesting culinary experiences I've had in the last
year - every bit equal to my trip to Brazil over a year ago. Chef Viet Pham and
Bowman Brown are two young culinary champions who are pushing new ideas and approaches
which deserve the attention of us foodies. I fully expect that they will be on James
Beard culinary champions in the future.

First the menus is a prix fix approach and, the price is amazingly low given the
quality of the menu. Let me start at the very beginning. The waiter brought us
butter from Iceland ("evidently, the cows are happier in Iceland") that had been
smoked onsite. It was exquisite. The winter squash appetizer was an outstanding
bit sized croquet with cream in the middle that swished around the mouth when you
bit into it. As a single bit, I could have had a full meal of these little nuggets.
Then, there was the scrambled egg served in the shell (British style) and layered
over a sherry cream sauce with maple syrup on the bottom. Wow!! The final appetizer
was a leathered apple wrapped around onion with a chestnut sauce. Again, exquisite.
At this point, they had my attention...

The next four courses consisted of: 1) kohirabi and a buttermilk and whey sauce
along with various grains and wild watercress; 2) wild pacific prawns in a bonito
sauce with pink peppercorns and capers and scallops covered in a pine nut ash (country
style); 3) lightly smoked sturgeon with a brown butter sauce, savoy cabbage roasted
on an open grill with fresh agrugula sprinkles and a soy caramel; and, 4) Utah duck
with served with apple and carrot plus dried beet roots; all topped with a duck
juice reduction sauce. Again, incredible...

At this point, I was reaching saturation but they brough on a wild rosehip sorbet
and yogurt combination and an elderberry and wild pine nut treat slathered with
a balsamic vinagrette dressing. The finale was an almond caramel with a raspberry
powder toppoing with a hint of salt.

I know that Salt Lake City is out of the way for most folks. But, if you get there,
make sure you stop in at this little bistro. You're going to hear from Viet and
Bowman in the future. So, if you get to the City by the salt lake, head to Forage,
370 East 900 South; Salt Lake City, Utah 84111; (801) 708-7834.

The Good, The Bad, And The Ugly

The ongoing saga...

The Good - It's the time of season where the absolute best good is being with family
and friends. I had that opportunity over the Thanksgiving holiday and hope you all
did as well. Be of good cheer...

The Bad - The turmoil in Egypt is very disconcerting. The foundations for democracy
seem very shaky with the renewed protests in Tahir Square. As one of the most important
countries in the Middle East and Northern Africa - let's hope that a representative
government comes together soon.

The Ugly - There was a tragic accident in China several weeks ago where a nine-seat
van crammed with 62 kindergarteners slammed head on into a coal truck in Gansu Province.
The accident killed 21 children and 2 adults. Now - that's ugly but, there is something
made the situation even uglier. The New York Times reported on Saturday, November
19, 2011 that: "...China's Twitter-like microblogs and other social media sites
have been alight with heartbreak and outrage over the tragedy - and, they have been
subsequently re-carded by government censors for unpatriotic emotion" [emphasis
added]. Now, that is ugly on top of ugly!!
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Founding Sponsor
Dearborn Advisors, LLC [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108882491881&s=6409&e=001MjbMnRnimS29LSW47kcl9TphBGvgBPezFSVKG02De5oczG7qvVcClWavlPqCblX-P5CnlJlcIOCNhUSZl6BVKZcT41s5I6-5MnsgFT9fwT0wmhFEMUKbFYFEZShfMAT8]
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