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The Jackson & Coker Industry Report is a compendium of healthcare news,
commentary, and other important information for busy physicians and hospital /
practice administrators. The monthly newsletter incorporates original research
and studies supplied to Jackson & Coker by a nationally recognized research
firm.
Clinical skills, workload, and medical liability protection don’t always equate with what doctors perceive as “adequate compensation.”
Practicing physicians are among the most highly compensated professionals within the healthcare industry. The question is, are they comfortable with their compensation level considering the demands placed upon them, the changes in reimbursement models, and the challenges facing our nation regarding the impetus toward major healthcare reform? Jackson & Coker addresses this question and related concerns in its latest annual Physician Compensation Survey.
Survey Impact and New Features
First of all, we were pleased with last month’s survey response. Over 1,000 physicians and health professionals expressed their strong opinions on healthcare reform, especially as it is packaged by politicians as “Universal Health Care.” And we are still tracking their responses!
By publishing respondents’ raw, unedited comments as part of the survey results, we were able to capture well-thought-out opinions of those who are on the frontlines of healthcare delivery, but whose voices are not always heard by those in other arenas. We transmitted the survey results to the campaigns of Senators McCain, Clinton and Obama. Time will tell whether their proposed health plans might be modified somewhat in consideration of our survey results and analysis.
Starting this month, we are presenting two new features. Our partnering research staff has written a Special Report on “Pay for Performance,” certainly a controversial topic throughout the medical profession. Determining how physicians are paid in terms of assessing the quality of their patient care is especially significant to the ongoing discussion.
A companion piece is a guest article by Tim Sheley, principal author who serves as Executive Vice President with Jackson & Coker, entitled “What’s a Doctor Worth?” An effective physician recruitment and retention program must take into account the direct and indirect costs of not having a doctor in place, costs associated with hiring a prime candidate, and the expected return on investment linked with a top revenue producer.
Lastly, we’re introducing a new article category: “Practice Management.” The articles we have selected address matters of extreme importance to physicians who are concerned about building a successful, profitable practice that meets the needs and concerns of a diversified patient base, while reducing malpractice liability and enhancing patient satisfaction.
There is a lot of exciting, informative content in this edition. Enjoy!
Cordially,
Calvin Bruce
Managing Editor
Physicians Face Medicaid’s April 1 Deadline for Tamper-Proof Rx Pads
Source: AMA News
Date: 03/24/2008
On April 1st, new Medicaid regulations go into effect that will require physicians to adopt tamper-resistant prescription pads. While various medical organizations claim most doctors are ready for the new regulations, efforts to inform still more continue.
The regulations require physicians to have at lest one measure on their written Medicaid prescriptions to prevent unauthorized copying, erasure, or modification. The new regulations were put forth as part of a bill on military spending passed in May of 2007 and developed by the Centers for Medicare & Medicaid Services in conjunction with various healthcare professional organizations.
The April 1st deadline is just a beginning. By October 1, 2008, prescriptions will require at least three security measures to meet Medicaid standards. While these standards are set by the states themselves—with Medicaid regulations serving as a baseline—a number of states haven’t chosen to go beyond the Medicaid-prescribed standards. The following is a list of the categories of features to be required by October 1, 2008, as well as a sampling of possible implementations:
-Features to Prevent Copying: pantograph, watermarking
-Features to Prevent Erasures or Modifications: non-white backgrounds, chemically reactive paper, paper-toner fuser
-Features to Prevent Counterfeiting: serial numbers, batch numbers, embedded metallic strips
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How Hospitals Can Prepare for the New MS-DRGs
Source: HHN Magazine
Date: 03/01/2008
Through 2008, the Centers for Medicare & Medicaid Services will roll out the most significant alterations to Medicare payment in twenty five years. The system—MS-DRG—is aimed at aligning CMS payment to actual treatment costs. The resulting system is more complex, and an article in the March 2008 issue of HHN Magazine explores the steps hospitals will need to take to adjust.
The article projects that the new guidelines will result in an increased workload for hospital coding departments, possibly reducing productivity by up to 50 percent. This will require greater collaboration between coders and clinicians for information sharing. The authors recommend an increase in staffing for coding and clinician departments and closer monitoring of the revenue cycles for hospitals as well as monitoring of coding practices.
In terms of financial input, the shift is likely to benefit the larger teaching institutions and urban facilities treating patients with higher levels of acuity. Rural hospitals and hospitals treating lower acuity level patients are likely to lose a noticeable amount of reimbursement revenue, though not an overwhelming amount.
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High Costs Force Third of Americans to Skip Needed Health Care
Source: The Washington Post
Date: 03/25/2008
According to a new study presented by the AFL-CIO, high costs in health care force one in three Americans to skip needed medical treatments. This is true, says the study, even among insured Americans.
The study—the online 2008 Healthcare for America Survey—surveyed 24,619 people between January 14 and March 3, 2008. Of those surveyed, 95% said healthcare needs fundamental change or a complete overhaul. More than 50% of insured respondents said their insurance couldn’t cover needed treatments at a cost they could afford. This ran across education levels as well, with a third of college graduates reporting that they had had to skip care at some point in the last year due to the cost of treatment. Among the uninsured, 76% said they or a relative had had to forego seeing a doctor while sick due to the cost of treatment.
The study’s authors and sponsors claim that the results of the survey are indicative of the overwhelming need for a restructuring of the current American healthcare system.
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Senate Hearing Questions Doctors’ Ties to Medical Device Makers
Source: American Medical News
Date: 03/17/2008
The U.S. Senate Special Committee on Aging met in February of this year to discuss the relationship between physicians and medical device manufacturers. A bill was proposed by Committee Chairman Senator Herb Kohl of Wisconsin that would require full disclosure of any gift worth over $25 from any medical device maker to a physician.
Between 2002 and 2006, the top 4 manufacturers of artificial hips and knees paid doctors over $800 million in consulting agreements. Though many of the payments were legitimate and fair, government officials argue, further investigation should be made to see whether device manufacturers were forcing their products on doctors in an unethical manner.
Most of the manufacturers involved in the case, citing existing disclosure practices at the company level, have denied any wrongdoing. The consulting agreements, they argue, are the best way to test and continually improve new equipment in a clinical setting. Some groups such as the Advanced Medical Technology Association, which represent the makers of nearly 90 percent of health care technology in the United States, created a code of ethics in 2004 that prevents doctors from receiving gifts totaling more than $100 at fair market value. While remaining compliant with the Senate’s investigations, these organizations seek to protect the valuable feedback they are receiving from physicians who use their new technologies.
The Senate group recognizes that over-regulating the physicians’ consulting market will ultimately harm medical practices in the United States. Their actions rather seek to prevent manufacturers from unfairly influencing physicians to use their equipment. The proposed bill would limit unnecessary perks while continuing to allow companies to use physicians as a source of research and development. Penalties for violating the bill would not extend to individual doctors.
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Hospitals Reuse Devices to Lower Costs
Source: Wall Street Journal
Date: 03/19/2008
To save on costs and reduce waste, hospitals are recycling a growing number of “single-use” products. A recent article in the Wall Street Journal examines the causes behind this recycling and delves into the question of its safety.
Reprocessing companies, hospitals, and environmental groups claim recycling is a safe process due to new procedures that lower risk of product failure or contamination. Reprocessing of medical equipment also results in equipment that is 40 to 60 percent cheaper than new materials. Furthermore, environmental groups state that thousands of tons of waste are eliminated from already crowded landfills through reprocessing. For their part, the medical device manufacturing industry counters by touting the higher risk of device failure, essentially calling the “single-use” label on their devices non-negotiable.
A recent study by the Government Accountability Office found no elevated risk incurred from the use of reprocessed single-use devices. Hospitals and reprocessing centers trumpet this finding as additional motivation for recycling medical devices. The process could save the healthcare industry about 1.8 billion dollars a year, according to Ascent Healthcare Solutions, a leading reprocessing company. Ascent also claims a reduction in waste of 1,684 tons by its customers.
Despite the protests of the device manufacturers, the reprocessing industry is thriving. The FDA has stepped up its oversight of the industry and is currently at work on guidelines and standards. Currently, efforts focus on ensuring the safety of patients as well as developing a notification system for patients who will be treated with reprocessed products.
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Steps to Better Board Accountability
Source: HHN Magazine
Date: 03/01/2008
According to a report by University of Iowa Researchers, nearly 90 percent of health systems boards have oversight of quality of care and patient safety, but only 43 percent have a standing committee to look exclusively at community benefit programs. With this figure in mind, a column in the March issue of HHN Magazine lists recommendations for improving hospital governance.
The article argues that hospitals need to do more to ensure fulfillment of their community benefit obligations on the whole, noting that the study should open the eyes of hospital administrators as to their obligations and the degree to which they are not meeting them in their particular hospitals. In the face of increased legislative scrutiny on hospitals, their finances, and the degree to which they serve their communities, the author makes the following recommendations on improving governance:
-Board development programs should be reviewed and improved to ensure board members are up to date with best practices in hospital governance.
-The board’s effectiveness should be regularly evaluated in a manner that can lead to substantial alterations to board policy and makeup if necessary.
-The board should state and assign responsibility for clear improvements in its structure to board members and subcommittees with authority to institute changes.
-The boardroom culture should be a healthy one that is conducive to change and adaptation and motivated for the improvement of the hospital on the whole.
-Governing boards should, as best as possible, reflect the diversity of the hospital’s staff and constituency.
-The board should focus on setting and meeting lofty goals regarding its community obligations.
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Coordinating Care - A Perilous Journey through the Health Care System
Source: The New England Journal of Medicine
Date: 03/06/2008
When patients see multiple physicians and specialists for their medical conditions, coordinating between different facilities and practices can be an administrative and financial mess. Opening communication between different physicians and reducing the number of duplicated medical tests can be crucial for limiting the costs to physicians and patients alike. Care coordination, defined as “the deliberate integration of two or more participants involved in a patient’s care to facilitate the appropriate delivery of health care services,” should be employed to simplify healthcare wherever possible
The New England Journal of Medicine recommends several key coordinated care strategies. Electronic referrals, where primary care physicians will send information on a patient’s condition to a specialist, is becoming increasingly popular. A dermatologist, for example, may only need to see the patient’s medical history and a photograph of the skin condition in order to make an accurate diagnosis. Referral agreements between a PCP and a specialist can also be made where the doctors agree what sorts of treatments should be handled by each physician. These agreements are typically rarer than electronic referrals, but achieve similar effects.
When a patient is in a hospital, there are also useful strategies that can be employed. Advanced-practice nurses can take over some of the responsibilities of overworked physicians or specialists while the patient is in the hospital. Other programs send advanced nurse “coaches” to recovering patients’ homes to educate their families about maintaining a basic level of care. Both of these initiatives save substantial sums of money by preempting an expensive visit to an M.D. in the hospital.
There are currently several problems associated with coordinated care. Primary care physicians are typically overworked and cannot handle the time commitment required to collaborate with other physicians. There may also be great discrepancies between different practices, such as how a patient’s medical information is stored on a computer, or how the physician will be compensated for his or her work. Small practices may be incredibly susceptible to these sorts of problems.
Despite these problems, there are many hospitals that have improved efficiency and costs by reducing unnecessary procedures and utilizing as few personnel resources as possible.
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PA’s Chronic Care Management Project
Source: Physician’s News Digest
Date: 04/01/2008
During the first six months of 2007, Pennsylvania’s hospitals reported over $2 billion in charges for persons with chronic conditions for “avoidable hospitalizations” as defined by the Agency for Healthcare Research and Quality. In other words, many patients in Pennsylvania are being unnecessarily hospitalized for chronic conditions, a trend that likely cost the state in excess of $4 billion over the course of the year.
This information was recently presented by the Chronic Care Management Reimbursement and Cost Reduction Commission (CCMRCRC), which has developed a strategic plan to:
-Implement a new primary care reimbursement model that permits primary care practices to provide additional resources to proactively care for patients with chronic conditions;
-Broadly disseminate the Chronic Care Model to primary care practices across Pennsylvania;
-Achieve tangible and measurable improvement in the quality of care for chronically ill patients; and
-Reduce the cost of providing chronic care and implement mechanisms to ensure that savings are realized by those paying for health care.
Ann Torregrossa, the deputy director and director of policy for the Governor’s Office of Health Care Reform in Pa., stated that many advisory members of the Commission were “telling us that, if we did not change how chronic care was being provided at the community level in Pa., we would continue to have serious quality and cost issues.” She acknowledges, however, that implementing their strategic plan faces many obstacles, including the lack of training patients receive in self-management of their conditions, which leads to an overreliance on primary care physicians, and the financial pressures physicians face to see as many patients as possible as quickly as possible to cover overhead costs.
The project being advanced by Torregrossa and others is based on the Wagner Chronic Care Model, which has six key components: self-management support, delivery system design, decision support, clinical information systems, partnership with community resources, and health system incentives for quality improvement among caregivers.
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The EDD’s Challenge
Source: LocumLife
Date: 07/01/2005
In 2005, a ruling by California’s Employment Development Department (EDD) raised concerns for locum tenens companies and physicians. Where physicians in locum tenens arrangements had always been considered “independent contractors” by their staffing firms, the new California law dictated that these doctors now be considered employees of the locum tenens organizations.
Several concerns surround this decision. The new rulings, first of all, make locum tenens firms culpable in any malpractice suits filed against physicians. The liability necessary to cover these suits is prohibitively expensive and may have forced many physicians to coordinate their own locum tenens employment opportunities within the state. Further, by establishing a more formal business arrangement between staffing firm and physician, the rulings placed non-physicians in a position to influence how doctors are practicing medicine. By taking away physicians’ status as independent contractors, there are serious concerns regarding doctors’ autonomy in the hospital or practice.
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Employment & Compensation
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Q&A: Common Questions About Locum Tenens Pay Rates
Source: LocumLife
Date: 03/01/2008
Fair and appropriate payment rates are a source of confusion within and outside the Locum Tenens (LT) community. An article in the March 2008 issue of LocumLife takes time to answer a number of commonly asked questions regarding the payment of locum tenens physicians.
Pay rates are determined primarily by the demand for LT services. While they may vary by location, locum tenens pay is largely determined by the demand for particular practitioners. LT professionals should take this into account when deciding on a region in which to practice.
While there is room for negotiation of pay—if, for instance, a doctor is ready to work longer hours or for a prolonged period at one location—pay rates are generally rather inflexible once agreed upon. Searching for higher pay in an area, shopping around services to other providers for higher pay offers, may in fact be in violation of a practice contract and can result in termination or legal action, depending on the contract.
-Pay is calculated typically on a per diem basis, with premium pay available for exceptionally long shifts or work weeks. Holiday pay rates vary according to many factors, including location, facility standards, and physician exceptionality. The physician doesn’t directly collect fees for services. The collection of fees is left up to the hospital or hosting institution.
-Locum tenens agencies pay the physician directly, after charging clients a slightly higher amount. The agencies generally handle the administrative and procedural legwork for locum tenens practitioners, justifying their cut by handling the logistical workload for physicians.
-Income taxes are the responsibility of the individual physician. Locum tenens physicians are paid as independent contractors and, as such, do not have taxes withheld. Locum tenens practitioners fill out Form 1099, and it is advisable to set up a special escrow account for independent withholding.
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Keys to Effective Physician Compensation
Source: Healthcare Strategy Group
Date: 01/01/2008
While indispensable to a practice’s operation, the development of an effective compensation plan for physicians can prove to be quit the headache. An article from the Healthcare Strategy Group examines the factors that must be taken into consideration in crafting a compensation plan.
Compensation plans must strike a balance between competitive physician compensation and competitive practice pricing. A number of methods exist for pricing plans, including fixed salary, productivity based pay, fixed salary with the added bonus of productivity incentives, and any of the preceding with added bonuses for meeting goals and benchmarks in quality of care. The article recommends taking patient charges, relative value units, and patient encounters into consideration when choosing which among these systems to employ.
In developing a compensation plan, the article has a number of suggestions. Chief among them is the establishment of clear expectations. In this manner, physicians know what is expected of them and what they’ll receive in return. Also important factors are the simplicity and sustainability of the plan. Overall, the article recommends a certain degree of flexibility in compensation plans to incentivize high performance.
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Why We’ve Never Been Sued for Medical Malpractice
Source: Medical Economics
Date: 03/01/2008
How could a six-doctor internal medicine and rheumatology practice never have had a lawsuit filed against it in 30 years of practice? Luck? Incomparable skill? The head doctor of the firm explains in an article in the March issue of Medical Economics that that record didn’t come cheap, but it is well earned.
The author notes that lawsuits often grow out of unrealistic patient expectations, though a certain degree of luck does help, and lays out nine factors and traits that have contributed to the practice’s impressive run:
-Document, ad nauseam: failure to diagnose is the most common trigger for a lawsuit. Thorough documentation, with fully articulated descriptions of patient conditions and proposed treatments, will not only insulate a practice from allegations of negligence, but also likely result in better treatment.
-Communicate with patients: practices should have incoming calls answered by a person, not a machine. Calls should be returned as soon as possible to ensure prompt assessment of a patient’s condition. Contact should be maintained with patients, for it will make them feel as though they are a part of their treatment, which will make them more likely to volunteer information.
-Be available: the author urges same-day sessions for patients reporting urgent problems. If at all possible, patients should be seen immediately if they feel they need to be seen. This results in longer hours for the practice, but longer hours spent in the office are better than long hours giving depositions.
-Triage: the author recommends that physicians be liberal with referrals and insists on regular visits from difficult patients.
-Stay current: be up to date on the latest in Continuing Medical Education. A new technique could save a patient’s life.
-Practice health management: doctors should encourage wellness in their patients, counseling them away from bad lifestyle choices such as unhealthy eating and smoking.
-Weed out bad apples: if you must “fire” a patient, do so. But do so in non-confrontational language that ensures the patient knows the practice is still there to help with record transferal, referrals, and provision of emergency care if necessary.
-Consider extrinsic factors: take a look at your malpractice insurance carrier. The author says the quality of the carrier is a huge factor. The quality of representation available is also a factor, as is the carrier’s willingness to settle cases.
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Where Does the Physician’s Duty to Warn End?
Source: Healthcare Review
Date: 02/28/2008
Does the physician’s duty to warn of potential side effects extend to third parties with no relationship to the physician? Yes, says the Massachusetts Supreme Court, in a case that could have an impact on practices nationwide.
The case—Coombes v. Florio—centers on an accident involving a ten year old boy, Kevin Coombes, who was struck and killed by a patient under the influence of a certain medication that impaired their ability to drive. The boy’s estate sued the prescribing doctor, who had been coordinating the treatment of the patient, claiming that his insufficient warning of the side effects of the medication made him liable in the boy’s death. The court’s finding, a majority opinion, was that the doctor could indeed be found liable by a jury for negligence leading to the boy’s death.
The trial may very well proceed to a jury, and so the author of the column believes it may raise issues for physicians on a wider scale. On the whole, the author recommends that involved parties do their due diligence and more to explain to patients and caregivers the potential side effects of medications. Thorough discussion of the side effects should also be thoroughly documented to limit physician exposure in these and similar cases in the result of litigable mishaps.
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Avoiding Legal Traps in Health Care Growth with Non-Profits
Source: Healthcare Review
Date: 03/25/2008
In the face of a constantly shifting healthcare industry, with advancements in technology and treatment and shifting demographics, it is easy for providers to lose track and fall behind the times. An editorial in Healthcare Review, however, states that administrators must stay on their toes with regards to their non-profit status in order to avoid legal troubles.
The article argues that the variety of state laws and regulations determining non-profit responsibilities can have the effect of creating pitfalls for charitable institutions. A hospital’s non-profit or charitable status can shift with something as simple as a gift or endowment that is deemed to be not in keeping with the will of its initial donors. Pitfalls are possible in mergers and decouplings of institutions, and great care must be taken in navigating the legal landscape for hospitals, which likely lack the financial resources for protracted legal battles over the minutiae of bylaws.
The author recommends the retention of a lawyer well-versed in charitable trust law, just in case a particular institution’s state laws prove treacherous to the uninitiated.
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Expert Who Changed Mind Claims Immunity, but Plaintiffs Still Sue
Source: American Medical News
Date: 04/14/2008
A U.S. District Court will soon consider a case in which two plaintiffs are suing their physician expert witness for medical liability after the doctor changed his opinion during pretrial proceedings and their (the plaintiffs’) lawsuit was eventually dismissed.
The original lawsuit brought forth by Thomas and Karol Pace was against anesthesiologist Stephen Shuput, MD, one of the doctors who treated and released their daughter after breast augmentation surgery. She died shortly after her release, prompting the medical liability suit.
The current lawsuit, filed in Utah state court, accuses anesthesiologist Barry N. Swerdlow, MD, of malpractice, fraud, negligent misrepresentation, breach of fiduciary duty, breach of contract, breach of the implied covenant of good faith and fair dealing, and negligent infliction of emotional distress. The couple alleges that Dr. Swerdlow, acting as an expert witness in their case against Dr. Shuput, unlawfully changed his position after his initial court deposition, and that this decision was a proximate cause of the state court judge's decision approximately a month later to dismiss their medical liability claim against Shuput.
Having requested and received a copy of Dr. Shuput’s deposition after giving his own deposition, Dr. Swerdlow amended his deposition to say that he thought Dr. Shuput’s care and specifically his decision to discharge the Paces' daughter, was within the standard of care. In the ruling, the Utah judge stated that one of the reasons the claim was dismissed was that Dr. Swerdlow’s deposition testimony and addendum failed to meet the grounds necessary to pursue any medical malpractice claims. Rather than appeal that decision, the Paces sued Dr. Swerdlow. They alleged that his change of opinion on the eve of trial was the “proximate cause” for the state court to dismiss their medical liability claim against Dr. Shuput.
Under the doctrine of witness immunity, a plaintiff cannot sue defense witnesses for an adverse judgment under the theory that expert witnesses should be permitted to testify freely without fear of finding themselves liable for their testimony, but the Paces argue that other federal jurisdictions that have addressed this question have refused to allow an exception to bar plaintiff claims against friendly experts.
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Bypass of Local Primary Care in Rural Counties: Effect of Patient and Community Characteristics
Source: Annals of Family Medicine
Date: 04/01/2008
What factors affect the likelihood of rural patients seeking care outside the local community? Is such bypassing a result of hospital size? Availability of primary care providers? A study in the March-April issue of Annals of Family Medicine examines the incidence of bypass and its causes.
The study looked at data from a 2005 telephone survey of 1,264 adults who lived within 20 to 25 miles of randomly selected critical access hospitals. This data was then compared with a Health Professional Shortage Area study and 2004 Census data.
The study found that 32% of respondents had bypassed local primary care at some point, with incidence of bypass ranging by region from 9 to 66 percent. Affecting factors were age, education, marital status, local hospital satisfaction, health, and local hospital size. Residents in areas with lower densities of primary care providers were more likely to bypass their local hospitals than were residents in higher density areas. Lack of specialists and limited service offerings were the most frequently cited causes of local hospital bypass.
The authors of the study conclude that strategies to encourage local hospital use should be directed at the individual and facility level as opposed to a broader plan. Local hospitals need to increase the familiarity levels of their surrounding communities with their offerings and services. This would serve to raise consumer confidence in the local medical establishment. Furthermore, an increase in the number of primary care providers is also recommended for low-density areas.
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Payer & Reimbursement Issues
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Insurers Begin to Reimburse Physicians for Online Visits
Source: iHealthBeat
Date: 03/31/2008
In a move viewed by some as the beginning of a possible trend, health insurers Aetna and Cigna have announced that they will reimburse physicians for online visits and also require a copay from patients.
The two companies maintain contracts with RelayHealth, which provides a secure site to doctors for administrative duties and other features. Patients complete questionnaires on the RelayHealth site that can aid doctors in the preliminary diagnosis of around 150 illnesses. Aetna announced it was expanding its pilot program with RelayHealth beyond California on January 1 of this year, while Cigna indicated that their program will begin in January of 2009.
The site functions predominantly as a means to streamline physician administrative duties and is relatively scarcely utilized, though industry figures believe that the online component of healthcare is bound to increase greatly in popularity in the coming years.
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Outlook Remains Bleak for Two Programs
Source: New York Times
Date: 03/26/2008
The financial outlook for the nation’s Medicare and Social Security Programs is grim according to figures released by the Bush Administration. A new report, detailed in the March 26 edition of the New York Times, warns that Medicare will exhaust its hospital insurance trust fund by the year 2019.
The report is likely to put pressure on the remaining three presidential contenders to expand upon their proposed solutions to the solvency problems of Medicare.
Medicare has a separate trust fund for the payment of doctors, and the trustees see a steep increase in operating costs, though the fund will not run out of money upon expiration of its trust fund due to its access to general revenue and adjustable benefits, characteristics that are built into the program by law.
Currently, the standard premium for Medicare Part B is at $96.40 per month, having increased some 64% over the last five years. At the present formula, it would stay level through 2010. However, figures in the report—which takes into account actual costs as opposed to costs including projected payout cuts—indicate that the premium is bound to rise. For their part, both parties in Congress appear to be busying themselves with laying blame for the coming insolvency and the deadlock over what to do about it at each other’s doorsteps.
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Bill Advances to Suspend Medicaid Cost-Shift Rules
Source: The Wall Street Journal
Date: 04/10/2008
Recently, the House Energy and Commerce Committee's health panel unanimously passed a bill that would block certain Medicaid rules that many states said would shift billions of dollars of costs to them. The bill would put a moratorium on seven rules that would end federal payments for physician training and transportation of Medicaid-eligible children to school, among other initiatives.
Because the Congressional Budget Office has estimated that the seven rules would save the federal government $1.65 billion for fiscal years 2008 and 2009, the onus is on lawmakers to find savings elsewhere. To help reach that number, the current bill requires more scrutiny of Medicaid beneficiaries' eligibility. The expectation is that some will be disqualified because their assets exceed the program's guidelines. In addition, Commerce Committee Chairman Rep. John Dingell offered a version of the legislation that would give the Department of Health and Human Services an additional $25 million a year to reduce Medicaid fraud and abuse, thereby cutting overall costs.
The moratorium on the rules has unique bipartisan support: all of the nation’s governors support the bill as a welcome relief from other budget crunches. Medicaid accounts for 20 percent or more of state spending, and the number of enrollees tends to rise when the economy slows down.
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Credentialing, Licensure, Quality Management
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Medical Errors Costing U.S. Billions
Source: The Washington Post
Date: 04/08/2008
According to the fifth annual Patient Safety in American Hospitals Study, patient safety errors resulted in 238,337 potentially preventable deaths of U.S. Medicare patients and cost the Medicare program $8.8 billion between 2004 and 2006. Released by HealthGrades, a health care ratings organization, the analysis was based on 41 million Medicare patient records and found that the overall medical error rate was about three percent for all Medicare patients.
Among the study’s other major findings:
-Patients who experienced a patient safety incident had a 20 percent chance of dying as a result of the incident.
-The most common types of medical errors were bed sores, failure to rescue, and post-operative respiratory failure. Together, they accounted for 63.4 percent of incidents.
-Of the 270,491 deaths that occurred among patients who experienced one or more patient safety incidents, 238,337 (or 88%) were potentially preventable.
-If all hospitals performed at the level of the top-ranked hospitals, about 220,106 patient safety incidents and 37,214 patient deaths could have been avoided, and about $2 billion could have been saved.
Officials at HealthGrades emphasized the importance of poor-performing hospitals recognizing that the benchmarks set by the Distinguished Hospitals for Patient Safety are achievable and associated with higher safety and markedly lower cost. Doing so would likely alleviate the current toll of lives and dollars that burdens health care systems.
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Hospitals That Participate in Clinical Trials May Provide Better Patient Care
Source: ScienceDaily
Date: 03/25/2008
Participation in clinical trials appears to be tied to better patient care, according to a new report from the Duke Clinical Research Institute.
The study, based on analysis of data from 174,062 patients, looked at treatment outcomes for patients with specific heart conditions at 494 hospitals. It found that in-hospital mortality decreased with increased trial participation at hospitals. Patients at hospitals that had participated in trials showed significantly lower mortality rates than those at non-participating hospitals.
While the study’s authors hope the study will alleviate fears of administrators wary of participating in clinical trials due to costs and potential downsides, they posit that the real effect of trial participation on mortality rates is likely due to administrative and procedural structures in place in hospitals that are likely to successfully complete clinical trials.
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Hospital Medicine Mix-Ups Rising
Source: The Boston Globe
Date: 04/07/2008
According to a recent study to be published in the journal Pediatrics, medicine mix-ups, accidental overdoses, and bad drug reactions harm roughly one in 15 hospitalized children. That number is much higher than earlier estimates and highlights growing concerns among the public, thanks in large part to a few highly publicized cases in recent months.
Thanks to a new monitoring method, developed in part by the National Initiative for Children's Healthcare Quality, researchers found a rate of 11 “drug-related harmful events” for every 100 hospitalized children, which translates to about 540,000 children each year. While traditional methods of detection relied heavily on nonspecific patient chart reviews and voluntary error reporting, the new tool is a list of 15 “triggers” on young patients' charts that suggest possible drug-related harm, and it includes use of specific antidotes for drug overdoses, suspicious side effects, and certain lab tests.
Some patient safety advocates aver that the problem is even bigger than this study suggests because it involved only a review of randomly selected medical charts for 960 children treated at 12 freestanding children's hospitals nationwide in 2002. Furthermore, the study did not include general community hospitals, where most U.S. children requiring hospitalization are treated.
More than half of the problems the study found were related to overdoses of morphine and other powerful painkillers.
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Online Physician Communication
Source: Physician’s News Digest
Date: 03/01/2008
As the information age progresses, information technology has an impact on more and more areas of everyday life. How are computers and personal communication devices impacting the healthcare field? An article in the March 2008 issue of Physician’s News Digest takes a look.
Fully 31 percent of physicians have reported communicating online with patients in the first quarter of 2007. This was up from 24 percent in 2005 and 19 percent in 2003. While the telephone remains the predominant mode of communication, this growth speaks well to the increasing power of information technology in the healthcare world, as well as the increasing comfort of patients and physicians with information technology. Doctors are beginning to carry a greater number of personal communications devices—miniature computers that allow for more detailed communication and automatic alerts—on their person at all times. This allows for them to be reachable in more places with more capabilities at their disposal.
Surveys indicate that patients are also ready to have a greater reliance upon information technology in their healthcare experience. One survey found that 62 percent of patients wanted the ability to communicate electronically with their doctor. Another survey asking the same question put the number at 74 percent. Still other surveys indicate that patients are willing to pay $25 for online consultations with their physicians.
A number of issues arise from this IT surge—namely, privacy and security. A number of regulations are currently in place regarding electronic standards in medical record transmission and storage. Doctors should be aware of these particular regulations before undertaking any information technology upgrades to their practices. Despite the potential pitfalls of IT, the benefits seem to far outweigh the possible costs. IT implementations can lead to faster, more accurately practiced medicine at a lower cost to providers, payers, and consumers. For this reason, a large number of IT solutions have presented themselves to the healthcare industry, and this number appears to grow by the day.
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New Studies Show Benefits of IT on Patients
Source: Healthcare IT News
Date: 04/09/2008
According to 11 research studies conducted by the Center for Connected Health, a division of Partners HealthCare in Boston, connected health technologies are making it possible for patients to better manage their care. Researchers found growing evidence demonstrating the benefits of “connected health” for patients, healthcare providers, employers and payers, as well as for the person who simply wants to stay healthy.
Examples of connected health technologies advocated by Partners include the following:
-A telemonitoring program for heart failure patients: Non-homebound heart failure patients participating in the Connected Cardiac Care program were given home telemonitoring equipment to transmit daily vital signs and symptom reports to a nurse. Initial feedback from participants has been overwhelmingly positive, with all patients reporting that the program has improved their overall health and helped them stay out of the hospital.
-Blood sugar monitoring for diabetes patients: Electronic communication between providers and patients outside of scheduled office visits was seen as important in improving diabetes management, and patients have reported that blood sugar monitoring was most valuable when newly diagnosed or for patients trying to regain control of their diabetes.
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Georgia Urges Physician Uptake of EHRs
Source: Healthcare IT News
Date: 03/31/2008
In what some have called a tremendous opportunity to transform healthcare delivery in Georgia, the Georgia Department of Community Health launched an electronic health records (EHR) initiative aimed at increasing the adoption of EHR among small and medium-sized physician groups.
The state plans to apply for participation in a Centers for Medicare and Medicaid Services-sponsored Medicare Demonstration Project, during which financial incentives will be provided to physician groups for EHR adoption and clinical quality benchmark achievement.
Proponents of the new initiative and electronic health records point out the potential benefits of EHR to patients, doctors, and healthcare organizations overall. In addition, they point out the potential cost savings for consumers, private payers, and government services as a reason for widespread adoption.
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Why Is It So Tough to Deliver on E-Prescribing’s Promise?
Source: Managed Care
Date: 02/01/2008
Electronic prescribing improves patient safety and reduces overall costs according to most industry experts. So why has adoption proceeded at a crawl? An article in the February issue of Managed Care magazine examines the impediments to E-Prescription adoption.
Only two percent of the roughly 1.5 billion prescriptions filed in the year 2007 were filed electronically. This ratio persists in spite of the demonstrable benefits of electronic prescription filing, which include dramatic improvements in patient safety and the accelerated adoption of other beneficial information technology in medicine. It has been calculated that errors and events possibly preventable by electronic prescriptions cost the healthcare industry and consumers approximately $27 billion per year. Major impediments to adoption of this life and money saving technology include the cost prohibitiveness—it can cost up to $27,000 for a practice to implement E-Prescribing hardware and software—and a general stubbornness among the physician community.
Industry figures are calling for a greater role to be taken by the government in the establishment of standards regarding electronic prescriptions. In particular, industry spokespersons call for faster adoption of the standards from the Medicare Modernization Act of 2003, which called for greater implementation of information technology in the medical administrative sphere. Attempts to modernize, though, are likely to run up against obstacles, such as current regulations that deem it illegal to transmit certain kinds of prescriptions electronically. Observers note that it will take greater cooperation between organizations, industry figures, and government to ensure operable standards that encourage adoption of technological solutions.
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Physician Practice Management
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Measuring a Practice’s Financial Progress
Source: Physician’s News Digest
Date: 03/01/2008
The business side of practicing medicine is often a necessary but distasteful necessity for physicians. However, come payday or tax time, having your financial house in order is as essential to the practice as the actual medicine. An article in the March edition of Physician’s News Digest explores the ins and outs of keeping a tidy practice on the financial end.
The article lays out the four essential steps for a financially health practice:
-Set expectations with a budget: the author recommends the establishment of a budget at the beginning of each year for comparison with actual results throughout the year. Having a budget aids in guiding determination of a realistic amount of compensation for shareholders, as well as revealing anomalies in revenues and expenditures. Budgets should be prepared by financially experienced office managers or accountants if necessary.
-Cash management: maintenance of cash flow is essential to practice operation. The strength of a practice’s cash flow is determinable through a number of measures, such as turnover of receivables, insurance payments, and assets divided by liabilities. The cash flow of a practice is a figure to keep in mind at all times.
-Know your true net income: having a true picture of a practice’s net income is essential to developing a real grasp of the fiscal health of the practice. The use of receivables and payables in consideration of profitability is recommended. Practices ought to track profits through accrual methods and modified cash methods to maintain a true view of financial obligations and outlays.
-Understand revenue and expenses analytically: figures should be compared year over year to develop a picture of the norm for a practice and spot anomalies and inefficiencies. If you know your practice’s resting financial pulse, you can easily tell when something is amiss.
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Learning to Love the System You’re (Stuck) With
Source: The New Physician
Date: 04/01/2008
According to Richard Frankel, a health services and qualitative researcher who has spent the past 30 years studying clinician–patient relationships, improving the “interviewing skills” of all American physicians by 10 to 15 percent would transform the face of American medicine. His latest research suggests that it is not so much the amount of time clinicians spend with their patients in the exam room, but rather how that time is spent.
The shift in emphasis advocated by Frankel and his team recognizes that time is money, and that health care in the United States is a marketplace commodity rather than a social good. Through the lens of the “15-minute model”—which will remain the dominant model in health care services barring a significant overhaul of the current system—there are a few ways that physicians can make the most of the patient interactions they do have.
Dr. Dave Davis, a Toronto-based family physician, has consciously cultivated his listening skills and begins each office visit by asking the patient “What do you think is going on?” This helps him know the patient in a professional sense and can help avoid unnecessary testing. Davis says that these minor “communication techniques” establish a mutually agreeable template from which physicians can deliver targeted, quality care.
Frankel and his fellow researchers see a lot of similarities between Davis’s approach and the “four habits of highly effective physicians” that they formulated over a decade ago. Those habits are: 1) invest in the beginning of the visit, which is about greeting patients and negotiating the visit’s agenda with them; 2) eliciting the patient’s story; 3) demonstrating empathy; and 4) investing in the end of the visit.
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Chart Mistakes That Can Burn You
Source: Contemporary OB/GYN
Date: 03/01/2008
Documentation of a patient’s treatment can leave a physician open to a good deal of liability if one isn’t careful what one says. Seemingly innocuous statements could be the lynchpin for a plaintiff’s case if they are vague enough or can be construed to be misleading. An article in the March issue of Contemporary OB/GYN has notation pointers for the physician looking to avoid litigation.
The article names three main areas regarding charts and notation where physicians commonly run into litigable problems, giving general pointers on content and style that can help avoid costly lawsuits:
-Choose your words carefully. Be careful not to understate or exaggerate evaluative statements. Always use concise terms and avoid vague or noncommittal words, which leave room for questioning and conjecture.
-Filter what you write down. References to risk management or legal services leave open the possibility that a physician knew something was wrong with the treatment prescribed. Likewise, negative characterizations of patients can open the door to litigation, and undue conjecture can be shown as a sign of malpractice if a doctor assumes incorrectly on a patient’s status or history.
-Don’t omit critical information. Family input, confounding factors, and medical reasoning are all important factors that should be included in notation on a chart to provide a fuller view of a patient’s overall experience with treatment. This leaves less wiggle room for plaintiffs, further shielding a practice from litigation.
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Malpractice Consult: When You Need Tail Coverage
Source: Medical Economics
Date: 04/04/2008
Most malpractice insurance available today comes in the form of claims-made coverage rather than occurrence coverage, which means that insurance carriers will only cover claims that are filed while the policy is in force, not all incidents that occur during the policy period.
The author of this recent article in Medical Economics recommends that companies continuously renew their claims-made policy to ensure coverage for incidents that took place in previous policy years, back to when that policy began. If companies change carriers, however, or if individual physicians retire from practice, they will no longer be covered for events that transpired while the policy was in force—unless, that is, you purchase some form of tail coverage.
Tail coverage essentially turns a claims-made policy into an occurrence policy, so that all claims related to incidents that took place during the policy period will be covered regardless of when the claim is made. Almost all insurance carriers offer tail policies, according to the author, but they can be very expensive. Another, similar way to ensure continued liability coverage is through prior acts coverage, which will make new coverage retroactive to whatever date is set forth in the policy. Typically, costs are directly correlated with how retroactive the coverage is set (i.e., the more retroactive the coverage, the higher the premium).
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Have You Really Addressed Your Patient’s Concerns?
Source: Family Practice Management
Date: 03/01/2008
Family physicians often pride themselves on their connection to and knowledge of their patients. However, research has shown that between 30 and 80 percent of patient expectations are not met in routine primary care visits. What could physicians be missing? An article in the March 2008 issue of Family Practice Management explores what physicians need to do to better connect with patients and address their needs.
The article places a good deal of the blame for patient dissatisfaction squarely on physicians, noting that analyses of recordings of patient-physician visits show physicians redirecting patients within 30 seconds of the patient starting to express their concerns. Furthermore, patients are generally removed from decision making, and doctors display little empathy. As a remedy, the authors suggest the adoption of a more patient-centered communication approach to more actively involve the patient in his own care.
The patient-centered approach centers on eliciting and prioritizing patient concerns so that the treatment is not based solely on the physician’s estimation of the problem and the physician’s time constraints, but on the patient’s concerns and expectations as well. The authors recommend a more decompressed initial patient interview that allows the doctor to tease out patient symptoms and concerns. Patients should also be informed of their treatment options and the benefits and risks of all options. Ultimately, they believe, the overall climate of the visit is positively affected, resulting in a better doctor-patient relationship and better treatment on the whole.
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Lab Tests Don’t Make Diagnoses, Doctors Do
Source: American Journal of Medicine
Date: 02/01/2008
Dr. Joseph Alpert at the University of Arizona College of Medicine comments on the need for physicians to consider laboratory results of patients’ conditions in the scope of the general clinical picture. Relying too heavily on a singular approach for identifying disorders can result in unwanted and deleterious misdiagnoses.
Using acute myocardial infarction as the focal point of the commentary, Dr. Alpert discusses how certain indicators revealed in a laboratory test, for example abnormal blood troponin levels, are not the lone means for diagnosing the condition. He provides an example of a woman who was mistakenly diagnosed with myocardial infarction based on a single laboratory test taken following a negative reaction to anesthesia. When the woman applied for life insurance several years later, she was denied coverage based on her supposed condition.
The takeaway message from Dr. Alpert’s comments is that laboratory tests alone are an insufficient criterion for diagnosing complicated medical conditions. There may be signals that highlight the potential existence of certain conditions, but without considering a host of issues - from the patient’s medical history to a physical examination - diagnoses can never be certain.
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