HIPAA Mythology – Wait, Can I Say That?

“Knock, Knock.”       HIPAA Hippo                                                   “Who’s there?”                                              “HIPAA.”                                                                         “HIPAA who?”                                                  “I can’t tell you.”

A handful of events have disrupted our office over the past 25 years… tornados, snow storms, royal weddings and royal birth announcements… you know… the sort of stuff that distracts our staff from patient care for much of a given day. But being such a dedicated crew, they are back on task the next morning, as though nothing ever happened.

Leave it to our legislators to create a distraction that lasts for months. Thanks, HIPAA.

2500 years of our profession honoring a sacred oath has always seemed pretty clear. The kind of promise that stood the test of time. Simple and true.


Hippocrates, c. 460 BC – 370 BC:

“All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.”

Legislators never saw a rule that they couldn’t make more complicated. Of course, they’re a little sensitive about this stuff because they’re not as good as physicians at keeping secrets.

There are plenty of rules in HIPAA. I advise that you follow every single one of them. Our local and national organizations have offered regional flavor to the HIPAA laws in an effort to make each rule even more enticing. And every bit of advice you ever get, including my own well intended comments, should be filtered by your attorney.

Attorneys really like to do that sort of thing. It offers them a distraction from all that other legal stuff they have to do. In fact, entire law firms have been established just to focus on HIPAA. It costs a lot of money to enforce these laws. But privacy is very complicated, just ask Hippocrates. He took a whole sentence to clarify it.

If this HIPAA law were made too simple, then consultants and attorneys might not be able to attend those fancy conferences, sign those big corporate protection contracts, and pay their many bills. And besides, can’t physicians just pass the expense on to patients?

There is so much in HIPAA to keep us busy. But as if that’s not enough, some folks are still adding their own interpretations to these rules. Some offices are actually adding more rules. Enough already, don’t make this harder for yourself.

Many of the “rules” that I hear physicians worry about are simply not in the HIPAA laws at all. Yet physicians, patients, and staff continue spreading anxiety about some rule that they fear might be violated. Offices become frozen by their fear of rules. If only my children would so broadly interpret rules… never mind, that’s a different blog.

       Here are five myths.     These rules are Not in HIPAA:

The answer for all of these is: Yes, you can.

1. You can’t have a patient sign in sheet.  Yes, you can. The sign in sheet is not a problem. Just don’t link a patient’s name with a reason for the visit.

2. You can’t call your patient by name.   Sure you can. You can call patients back by name, just don’t comment upon the reason for the visit. And BTW, address patients as Mr. or Mrs. whenever possible, or until they tell you otherwise. It’s still a courtesy in this part of the world.

3. You can’t place a chart or encounter form on an exam room door.  Yes, it’s ok to place a chart on the door. Just make sure no info beyond a name is readily seen. HIPAA requires that an office uses reasonable effort to protect privacy. (Like Hippocrates.) But patient sign in sheets, and charts on a door, are considered instrumental to the process of delivering healthcare. This doesn’t mean that staff should skip down the hall singing each patient’s name and diagnosis, even if it’s musical day. You have that day, don’t you?

4. You can’t leave an appointment message reminder on a voice mail or postcard.  Sure you can. Again, just don’t express the nature of the appointment or the reason for the visit, but you can say it’s time to come back to the clinic. This is another great marketing tool that improves healthcare. It’s called a courtesy reminder. There’s that word again.

5. You can’t allow the patient to bring a cell phone or laptop into the exam room. Heck yes, you can. The effort to prevent illegal recording of documents is important. Never leave records open or unsupervised. But you don’t have to be the cell phone police. Those long exam room waits get boring without angry birds and words with friends.

HIPAA rules can be challenging enough without over-reaching and stretching the guidelines. It is hard enough to follow the real rules. Sometimes the oldest rules are the strongest. And common courtesy is the rarest of all.

Just like Hippocrates.

Be sure to send me your own examples of HIPAA myths.

And don’t hesitate to bounce this stuff off your attorney. If lawyers get bored… they may write even more rules for us to over-interpret.

Guy L Culpepper, MD

Accountable Care Organizations – The Emperor

The Emperor’s New Clothes – Now About That Emperorthe_emperor__s_new_clothes_by_angelarizza-d5fc1wp

“Light as a spider’s web,” said the Emperor, as he wrapped the invisible cloak around his naked, royal buttocks.

While the weavers were cutting the invisible cloth and twisting the invisible thread, one after another of the Emperor’s staff commented on the magnificence of the garment. Not one of them chose to admit that he was unable to see the beauty, for fear of being judged inadequate. How then, could the Emperor himself confess that he couldn’t see the robes?

I have written about the weavers and the nature of the cloth, but the real story here is about the Emperor. Only the Emperor could stop the charade.

As physicians, and in particular primary care physicians, we are given the opportunity to seek truth. We are trained to look, listen, and touch so that we might see past the complaints and through the noise to find the true source of a problem. We are tasked with honesty, even if those around us, including at times our patients, are not so encumbered.

Our diagnostic skills do not seem to extend to our perceptions of healthcare systems.

The goal of an ACO is to lower cost by empowering PCPs to collect data and then make informed, cost effective choices to improve care. As I wrote previously, the weavers took control of the ACOs. That was never a surprise.

The startling thing is that PCPs have gone along with the charade, complimenting the weavers for their product. As if PCPs chose to see the   altered ACO as the way they wish it could be, instead of what it has become.

In January 2012, the Center for Medicare and Medicaid Services launched the Pioneer ACO Model. This was to be the banner bearer, the trail blazer, limited to only 32 organizations, chosen from 162 letters of intent from across the country. Those selected to participate were required to already have significant experience in coordinated care. Each was also required to have a minimum of 15,000 aligned Medicare beneficiaries. “Applications were reviewed by a panel of experts from the Department of Health and Human Services as well as from external organizations, with expertise in the areas of provider payment policy, care improvement and coordination, primary care, and care of vulnerable populations,” per the CMS report. 

The 32 networks selected were large, hand picked, stringently screened organizations, chosen specifically because of their high likelihood of success. If this were a pharmaceutical study, one would say that this was biased research, not fit for publication. The CMS wanted to ensure that they could show savings in their Pioneer ACO study, so they only accepted the participants that they thought would lower cost.       It didn’t work out.

The Pioneer ACO was to be a three year agreement, with a two year extension option. Now, in only its second year, 1/3 of the 32 expertly selected participants are dropping out… because they are losing money. Most of the remaining organizations are struggling to break even and are renegotiating their contracts.

Even after stringently selecting the participants for their Pioneer ACO, even after fancy accounting gymnastics, and even after investing hundreds of millions of dollars into the infrastructure, the CMS has to stretch to spin a positive.

The July 16, 2013 CMS press release can only point to 33 million dollars in savings to the Medicare Trust Fund for the 669,000 beneficiaries.

That’s $49 per patient. Total. For all of 2012. But please, pay no attention to the millions of dollars invested in the infrastructure, analysis, and start-up costs. We put that in a separate accounting category. It’s only tax dollars, anyway.

As PCPs, we still have an opportunity to get it right. Some of us even believe that we have a responsibility to get it right. Our Nation is counting on its primary care physicians.

The idea that PCPs can control healthcare cost with data and informed decisions is absolutely correct. PCPs are the best hope for the future of healthcare.

                           We do not have to be manipulated by the weavers                                                            or fall in line with our self-conscious advisors.                                     We have been empowered by our commitment to the truth. 

A large healthcare system with massive overhead, multiple agendas, and a giant pool of specialists in a limited geographic area can rarely reduce utilization. Especially over a long period of time. Usually the most significant savings can only be found outside of the large, vertically integrated system. To put it another way, sometimes a patient is better served by a competing facility. Period.

In order to provide the best possible care to our patients, independent PCPs must form networks. We already understand the core values of an ACO. We are the recognized leaders of cost effective care. PCPs are trained to work with multiple specialists and multiple resources from competing centers. New technology allows PCPs to share data and follow guidelines based upon performance and improved outcomes. We can reward behavior that results in healthier, happier patients. And primary care physicians certainly must be able to share in the savings that their efforts achieve. But to do all of this, PCPs must also control the infrastructure and the overhead. It must be our network.

Primary care physicians must be free and independent to utilize the healthcare resource that provides the best result for a given patient in a given circumstance. And that resource often changes depending upon the patient and the circumstance. Our patients, and our country, depend upon our unbiased decisions.

That’s the magic sauce. Independence, blended with honesty. The Emperor of healthcare, America’s primary care physician, must be independent.

And that primary care physician needs to put his clothes back on.

Guy L Culpepper, MD

Accountable Care Organizations – The Weavers

The Emperor’s New Clothes – The Weavers


Imagine the weavers staring at the naked, royal abdomen of the emperor. They knew full well the absurdity of the situation, but once the path of deception was taken, the weavers could only compliment their leader’s fine taste in clothing.

Last week I wrote about the clothing. Now, let’s take a closer look at the weavers.

An Accountable Care Organization, as a model of healthcare delivery, embraces the core values of primary care. The stated goals of measuring performance, improving efficiency, and coordinating care are undeniably worthwhile.

Rewarding primary care physicians to reduce the cost of healthcare

remains the right idea.

The ACO has the potential to do so much good. But the weavers got involved.

Hospitals, Insurance Companies, and Healthcare Entrepreneurs could see that the reimbursement system was changing. Billions and billions of dollars would be shifting from their control. 

Time to start weaving.

If primary care physicians were to be able to control costs, then the weavers knew that they needed to be able to control primary care physicians. 

The initial model of the ACO, proposed by the Medicare Shared Savings program in January 2012, empowered primary care to form networks with other providers to organize and coordinate delivery. That was the simple beauty of the ACO. Motivate PCPs. PCPs could use data to steer patients to more cost effective resources. By saving money, the PCPs could receive greater pay themselves. That would be a win for all.

Save primary care by helping primary care save money.

The problem for the weavers was simple. If PCPs saved money by keeping patients out of hospitals, referring to less expensive consultants, or using cost effective treatments… the money that they saved might be the weaver’s money.

That would never do. After all, weavers need lots of money… you know, to weave.

ACOs threatened to change the revenue of some very powerful and influential weavers. 

Those silly PCPs, they can’t save money on their own. The weavers must help these simple PCPs. Healthcare can only be delivered by complex, multi-layered vertically integrated networks. And these networks are very expensive because… well, they are expensive.

So messages were quickly spread:

Join an ACO or perish.

Don’t miss out. Never mind the details. Pay no attention to the beta testing. You need this. You want this. You got to be in this. We’ll worry about what an ACO is later. Sign up. Structure? Distributions?Ownership? This is the latest, greatest, new thing.

And just as with the Emperor’s new clothes, “only the ignorant” can’t see the beauty.

Physician’s anxiety to join an ACO was reinforced by….you guessed it…the very companies forming the ACO.  Hospitals, Insurance Companies, Specialists Organizations, and Entrepreneurs. Vertically integrated companies that much protect their market share, increase utilization, and support massive infrastructure. The very companies that contributed to our nation’s healthcare economic crisis. They don’t want to be part of the problem, they want to help….they just need lots of money to do it. 

And who are their key targets?  PCPs.

Remember that the only medical specialty required to form an ACO is primary care. So naturally all ACOs claim to be “primary care driven”. But ask who controls the revenue, who determines the overhead, and who steers the direction of utilization? Weavers are quick to point out the beauty of the clothing. But if you can’t see it, you must be ignorant.

In order to be recognized by the Department of Health and Human Services as an ACO the network must include sufficient numbers of PCPs to provide care for a minimum of 5000 patients. All of the other members of the ACO are infrastructure, overhead, and weavers.

So, if PCPs are the core component of an ACO, why don’t PCPs form their own ACO?

I’m so glad that you asked. I’ve written enough about the weavers.

Because, after all, only the Emperor himself could stop this charade.

Next week we’ll talk about the Emperor…  and oh, by the way…  you are the Emperor.

Guy L Culpepper, MD

Accountable Care Organizations – The Emperor’s New Clothes

The Emperor’s New Clothes

In 1837, Hans Christian Andersen published a tale about weavers promising the emperor a new set of clothes. These expensive robes would be invisible to anyone who was unfit for their position. If a person was ignorant or incompetent, they simply couldn’t see the new and majestic garments.
The emperor, of course, could see the clothes clearly.
Very few models of healthcare delivery have been as misinterpreted and manipulated
as the Accountable Care Organization, the ACO.
How an ACO appears is in the eye of the beholder.
My goal in writing this column is to look a little closer.
The term ACO was first used in 2006 as a possible Medicare payment structure.
It became a part of our healthcare jargon in 2009, when the recycled idea was included
in the Affordable Care Act.
The proposal that healthcare providers 
should be held accountable 
seemed to touch a national nerve. 
I mean, who could possibly disagree with the idea that healthcare should be accountable? Of course, as physicians, we knew that we were already accountable. We have been accountable for our actions since day one of medical school. Some would argue even sooner, considering the test scores required to get into medical school.
We are accountable to the State Board of Medical Examiners, DEA, Certification Boards, Credentialing Panels, Therapeutic Committees, countless rules and regulations like HIPAA.
We answer to every patient, their families, and their attorneys.
Oh, and one other thing…
we are accountable to the highest code of ethics of any profession in the world.
But an ACO is not that kind of accountability. This is financial.
The ACO model seeks to place financial accountability on healthcare providers in hopes of improving care management and lowering healthcare costs.
A noble and worthy pursuit, whose goal is shared by primary care physicians.
No one provides more cost effective care than PCPs.
This is why PCPs are critical, well… actually required, for the ACO model.
In fact, an ACO is like a three legged stool:
Primary Care
Payment Linked to Improvement
Performance Measurement

These three core principles are the foundation of the ACO model. But then the weavers got involved.

So let’s see where it’s gone since proposed. Here’s some background… fabric, if you will.

The Department of Health and Human Services (who is “accountable” for 25% of every dollar spent by our federal government… you may know them as those guys in charge of Medicare and Medicaid… but they are involved in so much more) proposed the initial guidelines for the establishment of ACOs under the Medicare Shared Savings Program in March, 2011.
ACO guidelines call for improved management and reduced expenses, that is care coordination.
The success of an ACO is based upon its ability to “incentivize” hospitals, physicians, and other providers. 

Pay attention now… this part is very important.
Incentivize” is business jargon for money. 
Kind of like when Medicare “incentivized” private insurers to get involved in Medicare by paying the insurance company massive amounts higher than Medicare rates.
In other words, ACOs could get lots of incentive money. That’s what the government does when it doesn’t know how to fix something… add infrastructure, regulations, and then incentivize.
Here it comes…
An ACO must have PCPs to get the money. Lots of PCPs means lots more money.
Now you understand why every hospital, insurance company, and healthcare entrepreneur wants to sign you up for their ACO.
But don’t worry, the ACO will be invisible.
Next week we’ll talk about those weavers.
Guy L Culpepper, MD

Welcome to the Jefferson Physician Group Blog

Dear JPG members… It’s been a long time coming.

Here we are – live on the web… and blogging.

During our 18 year history, the Jefferson Physician Group has used just about every form of communication to reach our members.

Some have been better than others.

“Did you get my letter…”      “I left you a voice mail…”
“It’s called a fax… yes, so don’t answer the phone…”
“I’m calling from my car… that’s right… a car phone!”
“I think we got a bad connection…”
“Do you have an email address…”

So many messages, so many dropped calls.

The challenge of communicating with primary care physicians is their schedule. No one checks messages quite the same way and never at the same time. Stacks of mail form on our desks like mushrooms, sprouting overnight on a field of information. A very big field.

Welcome to the blog. Information anywhere, anytime.

Log in late at night or early in the morning… you know, doctor time.

And even cooler… you can respond. Expand, agree, or disagree. Immediately. We will discuss, banter, and share. I know you have opinions. Express them.

A living document.
Collectively we can make more informed decisions for navigating through this sea of change. As always, we are better together.

You are part of a team. The Jefferson Physician Group.

This is your group. Stay involved.
Just like the video below.
Independence by Working Together. 

Welcome to the Jefferson Physician Group BLOG

Check back often for updates, news, topics of interest and forums for communication.

It’s an exciting time to be a primary care physician and to be a part of the Jefferson Physician Group… We’re glad you’re with us.

Guy L Culpepper, MD