Tax & Insurance Impact of Affordable Care Brian Meyers, CPA
Anders Health Care Services Work Smarter
LeagueOfHealthcareExperts.com 314-541-2220
Slide 3
2013 Tax Update Jessica A. Johnson, CPA Work Smarter
LeagueOfHealthcareExperts.com 314-541-2220
Slide 4
Agenda Fiscal Cliff Tax Changes Affordable Care Act Tax
Implications Examples Questions Planning Considerations Work
Smarter LeagueOfHealthcareExperts.com 314-541-2220
Slide 5
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
Slide 6
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
Slide 7
History of Tax Brackets Work Smarter
LeagueOfHealthcareExperts.com 314-541-2220
Slide 8
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
Slide 9
Alternative Minimum Tax Permanent patch introduced, adjusted
for inflation each year 60 million taxpayers spared from AMT
Slide 10
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
Slide 11
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
Slide 12
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
Slide 13
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
Slide 14
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
Slide 15
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
Slide 16
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
Slide 17
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
Slide 18
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
Slide 19
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
Slide 20
Individual Case Study 2012 Tax - $127,090 2013 Tax - $140,224
Increase of $13,134 Work Smarter LeagueOfHealthcareExperts.com
314-541-2220
Slide 21
Individual Case Study $5,595 $2,274 $5,265 Work Smarter
LeagueOfHealthcareExperts.com 314-541-2220
Slide 22
Planning Considerations Work Smarter
LeagueOfHealthcareExperts.com 314-541-2220
Slide 23
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
Slide 24
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
Slide 25
Affordable Care Act Work Smarter LeagueOfHealthcareExperts.com
314-541-2220
Slide 26
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
Slide 27
Tax and Regulatory Changes Work Smarter
LeagueOfHealthcareExperts.com 314-541-2220
Slide 28
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
Slide 29
Additional Regulations Pharmaceutical companies Insurance
companies Hospitals Medicare/Medicaid Tort litigations Medical
device manufacturers Work Smarter LeagueOfHealthcareExperts.com
314-541-2220
Slide 30
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%
Slide 31
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
Slide 32 200 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
Slide 33
Insurance Rebates Work Smarter LeagueOfHealthcareExperts.com
314-541-2220
Slide 34
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
Slide 35
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
Slide 36
Small Employer Health Insurance Credit Work Smarter
LeagueOfHealthcareExperts.com 314-541-2220
Slide 37
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
Slide 38
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
Slide 39
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)
Slide 40
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 41
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)
Slide 42
Calculating the Credit Report on Form 8941 Test for eligibility
Average wages = Total wages / FTE Work Smarter
LeagueOfHealthcareExperts.com 314-541-2220
Slide 43
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
Slide 44
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
Slide 45
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
Slide 46
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
Slide 47
Employer Mandate Work Smarter LeagueOfHealthcareExperts.com
314-541-2220
Slide 48
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
Slide 49
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
Slide 50
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
Slide 51
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
Slide 52
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
Slide 53
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
Slide 54
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
Slide 55
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
Slide 56
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
Slide 57
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
Slide 58
Questions Work Smarter LeagueOfHealthcareExperts.com
314-541-2220
Slide 59
Planning Considerations Review your current coverage Determine
if you need to make changes Watch for updates Work Smarter
LeagueOfHealthcareExperts.com 314-541-2220
Slide 60
Brian Meyers Anders Health Care Services (314) 655-5500
(Office) [email protected] Work Smarter
LeagueOfHealthcareExperts.com 314-541-2220
Slide 61
Comments? leagueofhealthcareexperts.com/worksmarter Work
Smarter LeagueOfHealthcareExperts.com 314-541-2220
Slide 62
Practical Applications of Technology Al Klein Managing Member
Omniscient HC Work Smarter LeagueOfHealthcareExperts.com
314-541-2220
Slide 63
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
Slide 64
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
Slide 65
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
Slide 66
How Data Is Stored In Your System Relationships Work Smarter
LeagueOfHealthcareExperts.com 314-541-2220
Slide 67
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
Slide 68
How Data Is Stored In Your System Constraints Foreign Keys
(Referential Integrity) Not in the Patient Table Work Smarter
LeagueOfHealthcareExperts.com 314-541-2220
Slide 69
How Data Is Stored In Your System Constraints Data Integrity
Result cannot be Empty Work Smarter LeagueOfHealthcareExperts.com
314-541-2220
Slide 70
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
Slide 71
How Data Is Stored In Your System Deletes - BAD Work Smarter
LeagueOfHealthcareExperts.com 314-541-2220
Slide 72
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
Slide 73
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
Slide 74
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
Slide 75
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
Slide 76
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
Slide 77
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
Slide 78
Addressing The Current Challenges But We Can Try! How? Work
Smarter LeagueOfHealthcareExperts.com 314-541-2220
Slide 79
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
Slide 80
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
Slide 81
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
Slide 82
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
Slide 83
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
Slide 84
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
Slide 85
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
Slide 86
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
Slide 87
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
Slide 88
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
Slide 89
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
Slide 90
Questions? Work Smarter LeagueOfHealthcareExperts.com
314-541-2220
Slide 91
Alfred Klein Managing Member Omniscient HC 314.581.8941 (m)
[email protected] www.nomeneo.com Work Smarter
LeagueOfHealthcareExperts.com 314-541-2220
Slide 92
Comments? leagueofhealthcareexperts.com/worksmarter Work
Smarter LeagueOfHealthcareExperts.com 314-541-2220
Slide 93
Enhancing Customer Service Through Improved Communication
Skills AMG Group League of Health Care Experts Work Smarter
LeagueOfHealthcareExperts.com 314-541-2220
Slide 94
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
Slide 95
"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
Slide 96
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
Slide 97
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,"
Slide 98
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."
Slide 99
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
Slide 100
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
Slide 101
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
Slide 102
Listening Skills Active Listening Whats different about it?
What gets in the way? Work Smarter LeagueOfHealthcareExperts.com
314-541-2220
Slide 103
Listening Listening is combination of what we Hear Understand
Remember Work Smarter LeagueOfHealthcareExperts.com
314-541-2220
Slide 104
Communication by the Numbers ___% Body Language ___% Tone of
Voice/Pace ___% Words Words Tone/Pace Body Language Work Smarter
LeagueOfHealthcareExperts.com 314-541-2220
Slide 105
% of Message Conveyed Via Body Language 1.15% 2.43% 3.55% Work
Smarter LeagueOfHealthcareExperts.com 314-541-2220
Slide 106
% of Message Conveyed Via Voice Tone/Pace... 1.18% 2.38%
3.49%
Slide 107
% of Message Conveyed Via Words... 1.7% 2.23% 3.56%
Slide 108
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
Slide 109
Are You Listening? Theyre NOT listening They ARE listening Work
Smarter LeagueOfHealthcareExperts.com 314-541-2220
Slide 110
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
Slide 111
Keys for Active Listening STOP LOOK LISTEN ASK PARAPHRASE Work
Smarter LeagueOfHealthcareExperts.com 314-541-2220
Slide 112
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
Slide 113
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
Slide 114
The most important thing in communication is hearing what isnt
being said. Anonymous Work Smarter LeagueOfHealthcareExperts.com
314-541-2220
Slide 115
Difficult Conversations Work Smarter
LeagueOfHealthcareExperts.com 314-541-2220
Slide 116
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
Slide 117
Difficult Conversations - The Three Layers - The Facts The
Feelings The Identity Issues Work Smarter
LeagueOfHealthcareExperts.com 314-541-2220
Slide 118
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
Slide 119
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
Slide 120
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
Slide 121
Difficult Conversations - The Three Layers - Recognize,
Acknowledge, Accept Benefits Build a Connection Make Better, More
Informed Choices Work Smarter LeagueOfHealthcareExperts.com
314-541-2220
Slide 122
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
Slide 123
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
Slide 124
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
Slide 125
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
Slide 126
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
Slide 127
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
Slide 128
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
Slide 129
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
Slide 130
Demonstrate Support Active Listening C-A-R-E Concentrate
Acknowledge Rephrase Empathize Work Smarter
LeagueOfHealthcareExperts.com 314-541-2220
Slide 131
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
Slide 132
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
Slide 133
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
Slide 134
I Statements Self-assertion Position on subject under
discussion Non-judgmental language Focus on facts Work Smarter
LeagueOfHealthcareExperts.com 314-541-2220
Slide 135
Reframing Take a second look Be open to different perspectives
and possibilities Work Smarter LeagueOfHealthcareExperts.com
314-541-2220
Slide 136
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
Slide 137
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
Slide 138
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
Slide 139
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
Slide 140
Thank You! Ann Grana AMG Group [email protected] www.amgccc.com
314-541-2220 Work Smarter LeagueOfHealthcareExperts.com
314-541-2220
Slide 141
Taking Your EHR to the Next Level Joe Wilmot Regional Sales
Consultant GBS Corp Work Smarter LeagueOfHealthcareExperts.com
314-541-2220
Slide 142
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
Slide 143
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
Slide 144
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
Slide 145
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 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
Slide 148
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
Slide 149
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
Slide 150
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
Slide 151
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
Slide 152
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
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
Slide 155
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
Slide 156
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
Slide 157
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
Slide 158
EHR Patient Reminder Technology Use Dashboards to monitor
compliance Work Smarter LeagueOfHealthcareExperts.com
314-541-2220
Slide 159
EHR Patient Reminder Technology Potential to enhance revenue is
real! Work Smarter LeagueOfHealthcareExperts.com 314-541-2220
Slide 160
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
Slide 161
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
Slide 162
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
Slide 163
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
Slide 164
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
Slide 165
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
Slide 166
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
Slide 167
Mike Spencer Regional Sales Consultant GBS Corp (314) 517-5054
(Cell) (314) 966-4692 (Office) [email protected] Work Smarter
LeagueOfHealthcareExperts.com 314-541-2220