Tax & Insurance Impact of Affordable Care Brian Meyers, CPA Anders Health Care Services Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

2013 Tax Update Jessica A. Johnson, CPA Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Agenda Fiscal Cliff Tax Changes Affordable Care Act Tax Implications Examples Questions Planning Considerations Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 across- the-board spending cuts) for another two months. New legislation made sequester cuts permanent Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

2013 Tax Brackets (Married Filing Jointly) Marginal Income RangesTax Rate $0 17,85010% $17,850 72,50015% $72,500 146,40025% $146,400 223,05028% $223,050 398,35033% $398,350 - $450,00035% Over $450,00039.6% Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

History of Tax Brackets Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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. Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Affordable Care Act 2013 Tax Changes New 3.8% Surtax on investment income Subject to SurtaxExempt from Surtax WagesX Taxable InterestX Capital GainsX Exempt InterestX DividendsX Annuity IncomeX Passive IncomeX RentsX Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Affordable Care Act 2013 Tax Changes Additional 0.9% Medicare tax on earned income Employees 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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Individual Case Study 20122013 Wages & SE Income$355,000 Investment Income 50,000 Long Term Capital Gains 20,000 Passive Income 20,000 Non-passive Income100,000 Less Adjustments (15,067) Adjusted Gross Income$529,933 Itemized Deductions $(60,000) $(53,102) Personal Exemptions (7,600)- Taxable Income$462,333$476,831 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Individual Case Study 2012 Tax - $127,090 2013 Tax - $140,224 Increase of $13,134 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Individual Case Study $5,595 $2,274 $5,265 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Planning Considerations Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Minimize AGI Harvest capital losses Minimize income from IRA distributions Dont 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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Minimize NII Invest in tax-exempt bonds Minimize investing in securities that pay dividends Increase participation to make passive income non- passive Convert passive income to salary (however, then exposed to.9% payroll tax) Capital loss harvesting Installment sales Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Affordable Care Act Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Overview Acts passed in 2010 Patient Protection and Affordable Care Act Health Care and Education Reconciliation Act Political environment Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Tax and Regulatory Changes Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Additional Regulations Pharmaceutical companies Insurance companies Hospitals Medicare/Medicaid Tort litigations Medical device manufacturers Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

200 employees automatically enroll in health insurance plans Out-of-pocket, premium and deductible limits Limit waiting period for coverage Work Smarter LeagueOfHealthcareExperts.com 314-541-2220">

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Insurance Rebates Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Small Employer Health Insurance Credit Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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. Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Firm SizeUp to $25,000$30,000$35,000$40,000$45,000$50,000 Up to 1035%28%21%14%7%0% 1133%26%19%12%5%0% 1230%23%16%9%2%0% 1328%21%14%7%0% 1426%19%12%5%0% 1523%16%9%2%0% 1621%14%7%0% 1719%12%5%0% 1816%9%2%0% 1914%7%0% 2012%5%0% 219%2%0% 227%0% 235%0% 242%0% 250% Source: Congressional Research Service, Summary of Small Business Health Insurance Credit Under PPACA (P.L. 111-148) 3 (Apr. 5, 2010)

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Slide #94 from CCH Firm SizeUp to $25,000$30,000$35,000$40,000$45,000$50,000 Up to 1050%40%30%20%10%0% 1147%37%27%17%7%0% 1243%33%23%13%3%0% 1340%30%20%10%0% 1437%27%17%7%0% 1533%23%13%3%0% 1630%20%10%0% 1727%17%7%0% 1823%13%3%0% 1920%10%0% 2017%7%0% 2113%3%0% 2210%0% 237%0% 243%0% 250% Source: Congressional Research Service, Summary of Small Business Health Insurance Credit Under PPACA (P.L. 111-148) 3 (Apr. 5, 2010)

Calculating the Credit Report on Form 8941 Test for eligibility Average wages = Total wages / FTE Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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) Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Employer Mandate Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Applicable Large Employer Employer who employed an average of at least 50 full-time equivalent employees on business days during the preceding calendar year. Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Penalties More likely the less employer contributes Wont be imposed on part-time employees under 30 hours Both the $2,000 and $3,000 penalties will be adjusted for inflation Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

All-Employee Penalty Watch classification of independent contractors Cost-benefit analysis of providing insurance Look for further regulations to be issued Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 full- time employees who actually enroll through Exchanges and receive a premium tax credit or cost-sharing reduction. $3,000 per employee not to exceed all- employee penalty Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 90 Less Reduction (30) Base for penalty 60 x 2,000 Penalty $120,000 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 90 Less Reduction (30) Base for penalty 60 x 2,000 Max Penalty $120,000 Penalty($3,000 x 1) $3,000 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Questions Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Planning Considerations Review your current coverage Determine if you need to make changes Watch for updates Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Brian Meyers Anders Health Care Services (314) 655-5500 (Office) [email protected] Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Comments? leagueofhealthcareexperts.com/worksmarter Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Practical Applications of Technology Al Klein Managing Member Omniscient HC Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

How Data Is Stored In Your System Tables Example: Patient PatientIDLastNameFirstNameDOBSSNGender 1SmithRobert4/5/1933111-22-3333M 2JonesJoan8/14/1957123-45-1234F 3WilliamsThomas11/29/1966453-75-8939M 4JohnsonEileen7/13/1922782-55-8392F 5BrownAndrew1/19/1972832-71-5738M 6SmithRobert9/9/1949312-63-6332F 7ThompsonNathan5/14/1939183-98-6765M 8YoungBeth12/18/1979583-81-5721F Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

How Data Is Stored In Your System Relationships Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

How Data Is Stored In Your System Constraints Keys (Primary and Foreign) PatientIDLastNameFirstNameDOBSSNGender 1SmithRobert4/5/1933111-22-3333M 2JonesJoan8/14/1957123-45-1234F 3WilliamsThomas11/29/1966453-75-8939M 4Johnsonileen7/13/1922782-55-8392F 5BrownAndrew1/19/1972832-71-5738M 6SmithRobert9/9/1949312-63-6332F 7ThompsonNathan5/14/1939183-98-6765M 8YoungBeth12/18/1979583-81-5721F 4GreenMichael6/19/1949844-48-4833M Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

How Data Is Stored In Your System Constraints Foreign Keys (Referential Integrity) Not in the Patient Table Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

How Data Is Stored In Your System Constraints Data Integrity Result cannot be Empty Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

How Data Is Stored In Your System Deletes - BAD Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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) Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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? Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Addressing The Current Challenges But We Can Try! How? Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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? / Whats 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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 isBuilding 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) [email protected] www.nomeneo.com Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Comments? leagueofhealthcareexperts.com/worksmarter Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Enhancing Customer Service Through Improved Communication Skills AMG Group League of Health Care Experts Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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)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. Its 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 Whats different about it? What gets in the way? Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Listening Listening is combination of what we Hear Understand Remember Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Communication by the Numbers ___% Body Language ___% Tone of Voice/Pace ___% Words Words Tone/Pace Body Language Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

% of Message Conveyed Via Body Language 1.15% 2.43% 3.55% Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

% 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 _7% Words Words Tone/Pace Body Language Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Are You Listening? Theyre NOT listening They ARE listening Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Listening filling in the gaps A person generally speaks 125 words per minute but can process over 400 words per minute. Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 patients 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? Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

The most important thing in communication is hearing what isnt being said. Anonymous Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Difficult Conversations Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Dont assume Dont 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 clinicians explanation; ensure understanding of medical issues involved Extended Family-directly address any present Document conversation including FEARED points Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 patients 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 Patients 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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Empathizing Demonstrates understanding of persons situation Listening for content, intent and emotion Watching for verbal and non-verbal CAREful Listening Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

I Statements Self-assertion Position on subject under discussion Non-judgmental language Focus on facts Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Im progressing? Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Thank You! Ann Grana AMG Group [email protected] 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 37 th 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? Patient Intake Patient Education Patient Reminders Patient Satisfaction EHR can make the difference by using Technology to take it to the Next Level! 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 Doesnt 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 patients 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 Patients own Clinical Data Specific Instructions that relate to Patients Condition Automatically note in patients chart that Patient Education was provided Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Enhanced Patient Education with EHR Automatically send context- aware patient education and summary sheets via patients email/portal Customized to specific components of the patients treatment Surgery, Procedures, Research, Outcomes 3-D Modeling Track Patient Interaction to Document understanding and informed consent 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 Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

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 Dont 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 Optimi zation 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 3 rd 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) [email protected] Work Smarter LeagueOfHealthcareExperts.com 314-541-2220

Documents

Tax & Insurance Impact of Affordable Care Brian Meyers, CPA Anders Health Care Services Work Smarter LeagueOfHealthcareExperts.com 314-541-2220