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Imagine health care delivery that maximizes
quality care to consumers, eliminates medical billing snafus, incorporates
modern technology into streamlining practice management, safeguards the incomes
of physicians who can spend more time treating patients--while eliminating the
need for insurance companies. Does
this sound too good to be true? Not
according to a revolutionary proposal offered by a health care executive with
over 30 years’ association with hospitals and physicians.
A physician who has previewed the plan comments: “Finally. The insurance companies are a
brokerage system that does nothing except increase the cost of care. Years ago, before the advent of
HMO’s, the cost of administering health insurance was 2-6%. With HMO’s it is 38-40%. As a practicing physician for 38
years with a degree in health management, I wish you success with your plan.”
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We have delayed publication of this issue of the Jackson & Coker Industry Report until after November 4.
Now that the presidential election is over, we know whose health care reform plan will be the focus of attention. Included in our roster of featured articles is an article selected from The New England Journal of Medicine discussing Senator Barack Obama’s proposal for improving health care in the United States. More detailed information concerning his plan can be accessed here.
Our monthly survey also addresses health care reform from another perspective. Mr. Rick Jackson, CEO of Jackson Healthcare (parent company of Jackson & Coker), has proposed a revolutionary revamping of health care delivery in the United States—beginning with eliminating third-party insurers across the board. Admittedly controversial, Mr. Jackson’s plan is intended to create dialogue concerning three important goals: improving patient care and making it more accessible to consumers, using technology to run medical practices more efficiently and cost effectively, and safeguarding the income of physicians and other health providers.
Along with our regular article content, we trust that Mr. Jackson’s proposal will be thought provoking and challenging to all segments of the medical community.
Cordially,
Calvin Bruce
Managing Editor
Obama’s Health Care Plan
Source: The New England Journal of Medicine
Date: 08/21/2008
In contrast to John McCain’s emphasis on free-market solutions and deregulation, Barack Obama’s health care reform plan relies on an employer mandate, new public and private insurance programs, and insurance-market regulation.
The core of the Obama plan is a requirement that employers either offer their workers insurance or pay a tax to help finance coverage for the uninsured. The plan would also create two new options for obtaining health insurance: a new government health plan and a national health insurance exchange that would offer a choice of private insurance options.
Both would be open to persons without access to group health insurance or other public insurance as well as to small businesses that wanted to purchase coverage for their workers. Income-related subsidies would be provided to help lower-income persons afford coverage, and private insurers would not be allowed to deny coverage because of preexisting conditions or charge substantially higher premiums to sick enrollees.
The Obama campaign says that the insurance exchange, by providing broader pooling and cutting marketing expenses, can reduce administrative expenses in private insurance and promote competition. The plan also calls for a new system of reinsurance.
Other cost-control measures include accelerated adoption of electronic medical records, paying providers on the basis of performance and outcomes, permitting the federal government to negotiate prescription-drug prices for Medicare patients, cutting excessive payments to private health plans contracting with Medicare, and establishing an institute for comparative-effectiveness research to generate information about effective treatments.
Obama has not ruled out adopting an individual mandate in the future if the plan does not produce universal coverage. The new national health plan could control costs, but its effectiveness in slowing spending would depend on its enrollment and the political willingness to restrain provider payments.
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Medical Providers: Are Your “Red Flags” Ready to Fly by November 1, 2008?
Source: Mondaq.com
Date: 09/28/2008
November 1, 2008 is the compliance deadline for the new federal “Red Flag” rules, adopted under the Fair and Accurate Credit Transactions Act of 2003 (FACTA). Although the act is directed at banks, mortgage lenders and other creditors, hospitals and other medical care providers are included in FACTA because health care providers extend credit to some patients, employees and physicians by offering extended payment plans. These payment plans are included in the act’s broad definition of creditors as “any person or business who arranges for the extension, renewal, or continuation of credit” with a “covered account.”
The “Red Flag” rules require health care providers and other creditors to adopt and implement an identity theft protection program that enables the health care providers to:
-Periodically determine whether it maintains covered accounts.
-Identify relevant patterns, practices, and specific forms of activity suggesting identity theft.
-Respond appropriately to any Red Flag that is detected to prevent and mitigate identity theft.
-Ensure the program is updated periodically to reflect changes in risks.
Health care providers must keep abreast of trends in identity theft including e-mails and voice communications that attempt to convince consumers into revealing private information as part of the regulations. Another component of the new rules is the requirement that the health care provider’s board of directors must become involved in the “Red Flags” program oversight.
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Study Polls Physician Views on Universal Healthcare
Source: MarketWatch
Date: 08/28/2008
A new study from DoctorDirectory.com assessed the attitudes of more than 850 physicians of all specialties on universal healthcare as it relates to the upcoming election.
Regarding the upcoming election, 81.3% have formed party and/or candidate preferences based upon the candidate’s stand regarding key issues.
While physicians have indicated that the economy, not health care, is the most important issue facing voters in the upcoming election, they are fairly evenly split with regard to the efficacy of universal healthcare as a means of improving health care in America. They were also split as to whether health insurance should be mandatory for all Americans.
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FDA Starts Reporting Drugs Under Safety Investigation
Source: Medical News Today
Date: 09/08/2008
On September 5, 2008, the Food and Drug Administration (FDA) posted its first quarterly report on the drugs it is investigating due to post-marketing problems reported by patients and doctors.
The reporting of FDA drug investigations is required under a new law, the Food and Drug Administration Amendments Act, which was passed in 2007. Patients, health care professionals and drug companies can report potential drug safety issues to the FDA through its Adverse Event Reporting System (AERS), and the FDA may choose to investigate certain drugs if AERS data warrant investigation.
The first quarterly report lists 20 drugs under investigation along with their potential safety issues, as revealed by AERS data. The FDA asserts that drugs listed in the report are only on the list because of a potential safety issue and have not necessarily been determined to be unsafe. FDA officials want to emphasize that doctors should not stop prescribing a drug just because it is on the list and patients should not stop taking their medications.
The FDA will release a new list every quarter, meaning it will not name any drugs that appeared on previous lists, even if they are still under investigation. Though the FDA has a system in place for drugs it determines to be linked to potential risks, it is not yet clear how the FDA will inform the public when an investigation “clears” a drug that appeared on the list.
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Course Teaches Medical Students Ways of Business
Source: Modern Physician
Date: 09/11/2008
For the second year, Northwestern University is offering an interdisciplinary course that brings together students and faculty from its schools of medicine, law, engineering and business. The course, called NUvention, instructs students on the medical product- and business-development process over two academic quarters, affording students a hands-on experience that reveals what it takes to bring medical advances to the market.
Northwestern receives financial backing from healthcare companies in order to provide the course. In its first year, NUvention included 82 students divided into 11 teams, each tackling an area such as cardiology, neurosurgery, orthopedics or urology. By the end of the course, teams had developed prototypes and full business plans.
Doctors at Northwestern’s Feinberg School of Medicine assert that the benefits of the course go far beyond the classroom. Patrick McCarthy, M.D., chief of cardiac surgery at Northwestern and NUvention’s medical director, says that the patients benefit as much as the students do, if not more so, as the course promotes bridging the clinical knowledge of physicians with the technical, legal and business strengths of students and professionals from the other fields. Feinberg School of Medicine professor and practicing cardiologist Randall Williams praises the course as a way to help physicians who are frustrated in their roles within a challenging healthcare system that does not make it easy to implement change.
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Diversity at Medical Schools Makes Stronger Doctors, Study Shows
Source: ScienceDaily
Date: 09/10/2008
While “diversity” is a value that has been much lauded by institutions of higher education, concrete data has yet to be produced on its benefits in the medical school context. The September 10th edition of the Journal of the American Medical Association contains a study of 20,000 graduating medical students from 118 medical schools that aims to do just that. This study, led by the UCLA Higher Education Research Institute, “explored whether the proportion of minority students within a medical school made a difference in three outcomes: First, whether students said they felt prepared to care for diverse patient populations; second, their attitudes about access to healthcare; and third, their plans to care for patients in areas that are traditionally underserved by the healthcare system.”
The study found that white students who attend racially diverse medical schools said they felt better prepared to care for patents from racial and ethnic groups other than their own than did students at less diverse schools. In addition, students at more diverse schools are more likely to view health care as a societal right rather than a privilege. As to the third question on the relationship between the diversity of a medical school and whether white students intended to provide care in underserved areas, no association was found.
While a diverse student body is a necessary step toward achieving the aforementioned benefits, the authors of the study note that a diverse composition is not sufficient for students to realize the full benefits of diversity. They found that positive interaction must be promoted in order to realize its full benefits.
By offering evidence for the benefit of diversity in medical schools, this study provides support for medical school policies and programs aimed at achieving racial diversity.
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The Doctor’s Hands Are Germ-Free. The Scrubs Too?
Source: The New York Times
Date: 09/22/2008
Amid growing concerns about hospital infections and a rise in drug-resistant bacteria, the attire of doctors, nurses and other health care workers — worn both inside and outside the hospital — is getting more attention. Though the importance of hand washing and equipment sterilization in hospitals has been well documented, little is known about the role that professional and casual clothing may play in the spread of bacteria.
Earlier this year, the British National Health Service imposed a “bare below the elbows” rule barring doctors from wearing ties and long sleeves, both of which are known to accumulate germs as doctors move from patient to patient. At most U.S. hospitals, physicians are asked to wear “professional” dress and told not to wear scrubs to and from the hospital, but have no strictly defined rules like those recently enacted in the U.K.
While the role of clothing in the spread of infection hasn’t been well studied, some hospitals in Europe have adopted wide-ranging infection-control practices that include provisions for the clothing that health care workers wear both in and out of the hospital. Stringent bacteria contamination precautions appear to have worked in Denmark, where fewer than one percent of staph infections involve resistant strains of the bacteria. Meanwhile, in the United States, the numbers have surged to fifty percent in some hospitals.
For American hospitals on tight budgets, implementing comprehensive clothing provision and laundry plans does not seem feasible and are unlikely to take hold while there is no conclusive evidence of their necessity.
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Traveling for Care – in the U.S.
Source: The Wall Street Journal
Date: 09/10/2008
Medical tourism, defined as the practice of traveling abroad to receive less expensive medical care, has become an increasingly common phenomenon. Recently, a new variant has arisen. As U.S. hospitals have begun trying to match lower foreign prices to stem the prospect of losing revenue overseas, U.S. employers are encouraging workers to travel domestically for medical care, especially surgical procedures such as hip and knee replacements and cardiac bypasses, in an effort to find new ways to manage medical costs.
In order to encourage such travel, employers are offering financial incentives including no out-of-pocket costs, money for travel expenses, and access to concierge services. For instance, Hannaford, a Scarborough, Maine-based company that has negotiated a deal for hip, knee and spine surgery with a hospital in Boston, has promised to pick up the entire tab for the procedure if employees go in the next year.
Healthplace America, a company that offers access to a specialty network of U.S. hospitals for various procedures, indicates that such networks can offer employers savings of 30% to 50% on rates negotiated by insurers because the company pays the providers upfront in cash based on fixed per-case rates. With soaring gas and food prices are pummeling their pocketbooks and the complications involved with traveling overseas for medical care, odds are that such arrangements will begin to appeal to employees as well.
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Academic Sites Adopt Conflict-of-interest Policies More Easily
Source: ModernHealthcare.com
Date: 09/02/2008
While relationships with medical companies can be of great benefit both to medical centers and medical researchers, academic freedom and scientific standards require that conflict-of-interest policies be instituted to protect against bias in teaching and research. It has been suggested that the stricter a conflict-of-interest policy becomes, the more likely it will be that centers will lose good faculty and staff--that is, individuals who wish to pursue relationships with the private sector.
A report that appeared in the September 3rd edition of the Journal of the American Medical Association indicates that this does not seem to be the case. According to Columbia University researchers David Rothman and Susan Chimonas, academic medical centers adopting strenuous conflict-of-interest policies have seen little loss of faculty and staff in reaction to the new standards.
This study of roughly 25 medical centers that have implemented new conflict-of-interest policies, most often in response to a conflict-of-interest policy recommendation published in January 2006 by an American Board of Internal Medicine and Institute on Medicine as a Profession joint task force, found that most often the result of a change in conflict-of-interest is a heated debate between healthcare providers and administrators.
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Human Resources: Physician Employment Agreements
Source: Physicians Practice
Date: 09/01/2008
The contract is the central part of any employment agreement and should be completed accurately and effectively in order to protect both sides. When hiring a new doctor, a lawyer who is familiar with medical practice models is ideal.
Financial terms are usually the simplest part of the employment agreement. A good contract will make it clear what is expected of the person being hired and what they should expect of the employer. The employer should have a good idea of how much they can afford to pay the new physician and how much business that physician must bring in to justify their income. Negotiations rarely break down over salary, as most candidates have roughly similar expectations.
Many practices depend on word of mouth and return business; so physicians’ contracts should explicitly state what sort of standard the employer expects to be upheld in matters of conduct. The system by which patients are allotted should also be specified, as well as appropriate and reasonable grounds for termination – without making the language too pejorative.
The employer is entitled to reasonably protect their own interests by preventing departing physicians from taking business with them. At the same time, candidates will not want to be unemployable in that community if they leave the practice for which they are interviewing. To find a middle ground, determine what the geographic area is that needs to be protected. A departing physician expects to relocate if they leave a small-town practice, but not one in a major city.
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Physician Recruiting: Finding the Keepers
Source: Physicians Practice
Date: 09/01/2008
In the midst of the national physician shortage, recruiting physicians is an increasingly difficult task for private practices. More and more practices feel pressured to offer perks like hefty signing bonuses, more flexible hours and fatter salaries to attract new doctors. Smaller practices are left at a disadvantage because they lack the resources to compete with the bigger practices and their attractive incentives.
When recruiting, a practice should assess its needs and determine the compensation package it will offer before entering the market. Top candidates today quickly identify and shun practices that appear disorganized. Practices will also need to develop a recruiting budget. Costs include advertising, transportation expenses from flying candidates in, and relocation costs for the new hire.
Private practices should look to initiate cost-sharing agreements with local hospitals. If a community need exists, a local hospital may be willing to cover some recruiting costs and/or guarantee the new physician’s income for the first year. Other tips include: 1) participate in local residency programs to get a first look at talent coming through the pipeline, and 2) look to professional associations for help publicizing physician staffing requirements.
When beginning the search for a new physician, getting the word out is the most important part. With regard to enticing applicants, experts believe that flexibility (through shorter work weeks, reduced call schedules, etc.) is the most attractive offer that could successfully draw new doctors to a practice.
Though the need to fill a position may feel urgent, it is unwise to hire the first qualified candidate who comes along. Instead, practices should consider hiring a locum tenens physician for temporary help while they take the time to review many candidates and find a strong permanent hire.
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Kadlec Decision Reversed: The Impact on Physician Recruitment and Credentialing
Source: Journal of the ASPR
Date: 06/01/2008
In May 2008, the 5th Circuit Court of Appeals reversed the District Court’s opinion which included a holding that Lakeview Medical Center (Lakeview) and Lakeview Anesthesia Associates (LAA) had a duty to disclose to Kadlec Medical Center that Dr. Berry, a former partner with LAA, had a drug problem when it made inquiry after Berry applied to Kadlec for medical staff membership.
The decision addresses the issue facing many hospitals of how to respond to inquiries about physicians who have had documented quality of care or impairment problems.
The holdings of the 5th Circuit Court can be summarized as follows:
-Although there is no duty to disclose, a party has an obligation to avoid affirmative misrepresentations in referral letters to another hospital.
-Once a party does disclose information about a physician which creates a “misapprehension” about qualifications, or if disclosures are misleading, it has an obligation to clarify the information provided.
-Regarding the question of legal causation, the Court held that LAA’s purposeful misrepresentations caused, in part, the injury to Dr. Berry’s patient who is now in permanent vegetative state as a result of his negligence.
The impact of the Kadlec reversal will be felt by hospitals in several ways:
-Although the decision concluded that Lakeview had no duty to disclose the physician’s impairment, liability was affirmed against LAA.
-The case law interpretation of duty to disclose varies from state to state. A hospital needs to review both its policies and its state reporting requirements to determine whether it is obligated to make disclosures to other hospitals regarding physicians seeking appointment or reappointment.
-Responses that are misleading or create misapprehensions may give rise to liability claims either from the inquiring hospitals or the physician.
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Employment & Compensation
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Title VII Grants Result in Physicians Who Work in Underserved Communities
Source: American Academy of Family Physicians
Date: 09/19/2008
The Annals of Family Medicine recently published a study analyzing the effects on Title VII’s primary care training grants from the federal government.
Study results showed that Title VII grant funding is an “important lifeline for many family medicine departments and residency programs.” Funding from the program was strongly associated with a strengthened educational system and increased physician staffing at community health centers and the National Health Service Corps.
The influence of Title VII on physician grant funding can be seen through a number of funding areas of the program. One component of Title VII that provides federal grants for training family physicians, Section 747, resulted in a substantial increase in the likelihood that physicians with degrees conferred from medical schools funded under Section 747 practice at a community health center.
Additionally, the study found that 3% of physicians who graduated from medical schools that received Title VII grant funding worked at community health centers, compared to 1.9% of graduates from schools without grant funding. Title VII funded residency programs showed similar results, with 6.8% of graduates working at community health centers during 2001-2003, compared to 5% of physicians who attended residencies without the grant funding.
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Building Physician Work Hour Regulations from First Principles and Best Evidence
Source: The Journal of the American Medical Association
Date: 09/10/2008
While regulatory standards for the work hours of physicians in training were passed in 2003, there has been a dearth of evidence indicating that these regulations have resulted in improved patient care. Kevin G. Volpp, MD, PhD and Christopher P. Landrigan, MD, MPH argue that this is due to the fact that these regulations are insufficient to their purpose: the thirty-hour shifts allowed do not avoid the problem of sleep deprivation, compliance may be suboptimal, and benefits from reduced fatigue might be offset by worsened continuity of patient care. In response, they propose priorities to guide the medical community in developing specific alternatives for physician work hour regulations that are designed to maximize patient and physician safety while preserving the best possible training for physicians.
The following are the principles proposed:
-Rigorously study alternatives for work hour reduction.
-Measure outcomes related to resident education.
-Improve “sign-out” procedures.
-Eliminate or minimize situations in which residents work 24 to 30 continuous hours.
-Improve monitoring of standards.
-Increase flexibility for implementation and enforcement.
-Recognize the importance of supervision and work intensity.
-Align incentives for payment with desired objectives.
The principles suggested are founded on the recognition that there is need for the value of alternative work hour arrangement to be established scientifically. Alternatives proposed are based on rigorous evidence.
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Survey: State Doctors Dissatisfied
Source: The Connecticut Post
Date: 09/01/2008
According to a recent poll, in the State of Connecticut, 30% of doctors are considering changing jobs or relocating to another state because they are dissatisfied with the practice environment --a result of low reimbursement rates for services, the high cost of malpractice insurance, and the high price of doing business in Connecticut. Ten percent said they planned to leave the state entirely, with 19% considering a career change for the same reasons, with fewer people joining the medical profession overall and 35% of respondents reporting difficulty in recruiting new physicians.
There is concern that the combination of factors described above may contribute to a physician shortage in Connecticut. Though there was anecdotal evidence of dissatisfaction among doctors in Connecticut, this is the first survey that has given statistical evidence of a “doctor drain.”
Doctors are responsible for their own expenses, which include staffing, utilities, and malpractice insurance--the last of these costs an average of $10,000 annually in the state of Connecticut.
Bringing new doctors into the profession is made more difficult by these costs as well. Medical students leave postgraduate education with large debt burdens, making them less likely to want to practice in a state such as Connecticut where costs might outweigh profits. This is compounded by the aging physician population: nearly 62% of doctors surveyed were 50 or over. Doctors are looking to the General Assembly for changes, such as lower malpractice premiums and better insurance coverage for low-income residents to offset these difficulties.
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Choosing Your Medical Practice Entity
Source: Physician’s News Digest
Date: 09/01/2008
When starting one’s own medical practice, one of the first decisions to be made is the choice of legal entity for the medical practice. It is important to consider the characteristics associated with each type of entity before making a decision.
A Sole Proprietorship is essentially just the physician operating a business. Income and losses are reflected on your personal tax return. No personal liability protection from creditors’ claims against the practice is provided, but the largest exposure faced will probably be from a malpractice claim. No one else can own a part of the entity. If you plan to bring in partners, you do not want a sole proprietorship.
A General Partnership is rarely an appropriate form of entity for a medical practice.
A registered Limited Liability Partnership (LLP) is a partnership that registers with the state in order to obtain limited liability for its partners. An LLP does not pay income taxes at the entity level; instead, income and losses are passed to the individual partners. However, an LLP must file a tax return reflecting the amounts passed to owners. There are tax consequences each time a new partner is admitted.
A Professional Limited Liability Company (PLLC) provides shelter from debts of the entity not caused by an individual’s own malpractice. If the PLLC has more than one owner, rights and duties of each owner are set forth in an operating agreement. Incomes and losses are “passed through” to owners. State registration fees may exist. A PLLC may appeal to a sole practitioner who intends to expand the practice. However, adding owners necessitates an operating agreement.
The Professional Corporation (PC) designation shields its owners from liabilities related to malpractice of professionals that are not directly supervised by that owner. It is generally less expensive to form and maintain. Corporate by-laws provide for its governance. A PC must file annual tax returns, paid at the corporate level unless otherwise elected. No annual registration is required. A PC may appeal to sole practitioners who intend to expand over time.
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Liability Reforms Bring More Care, More Doctors to Texans; TMA Physician Survey Confirms: Prop 12 Was Good For Texas
Source: Medical News Today
Date: 09/11/2008
The twin threats of lawsuits and high professional liability insurance premiums are powerful enough to cause doctors to shy away from high-risk services and procedures, complex and high-risk patients, and high-risk specialties. In 2003, Texas undertook drastic liability reforms – the cornerstone of which was a $750,000 cap ($250,000 for physicians, $250,000 for the first hospital or health care facility, and $250,000 for any additional facilities) on judgments for noneconomic damages, such as pain and suffering, in health care liability cases – in order to address the problems that the medical liability climate had created.
The 2008 biennial “Liability and Access to Care Survey” by the Texas Medical Association, designed to measure physician’s actions and attitudes concerning the Texas reforms, has found that the state’s landmark health care liability reforms have succeeded in bringing more physicians to Texas, in making entrance into high-risk specialties more attractive, and in encouraging physicians to provide more services and care to patients with complex or high-risk problems.
Specifically, this survey found that:
-“Almost 90 percent of the survey respondents ‘strongly agree’ or ‘agree’ that compared with 2003, they now feel more comfortable practicing medicine in Texas in the manner in which they were trained.”
-“Eighty-five percent said the improved liability climate played a ‘very important’ role in their decision to begin accepting complex or high-risk cases.”
-“More than 90 percent of the physicians who have successfully recruited new physicians to their practice, hospital, or community say the new liability climate was ‘very’ or ‘somewhat’ important in that success since 2004.”
In addition, it was found that in the wake of these reforms, a number of free clinics have been established. Hence, consensus is that these reforms have not only raised the standard of care for individuals with health insurance, but also individuals without insurance coverage.
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Ruling: Hospital May Not Take Corrective Action against a Physician Based Solely On Peer Review Findings from Other Hospital
Source: Mondaq
Date: 09/11/2008
In 2002, Hanford Hospitals suspended the medical staff membership and clinical privileges of Dr. Branton R. Smith, charging him with substandard care, abusive behavior, and falsification of records. Dr. Smith challenged the decision through the peer review process. When the governing boards at Hanford affirmed the suspension, Dr. Smith filed suit against Central Valley, one of the Hanford Hospitals.
Eight months after informing Selma Community Hospital--a second hospital with which Dr. Smith was affiliated--of the suspension at Hanford, the Medical Executive Committee (MEC) at Selma summarily suspended Dr. Branton R. Smith’s medical staff membership and privileges at Selma based solely on his summary suspension at Hanford. In response, Smith sued the Community Hospital.
The recent decision of this lawsuit provides important national guidance for peer review bodies. In Smith v. Selma Community Hospital (Smith), the California Court of Appeal, Fifth Appellate District (Court) held that, unless circumstances indicate otherwise, a hospital may not rely solely on the peer review findings of another hospital when considering whether to terminate a physician’s medical staff membership and clinical privileges if there is evidence questioning the reliability of the prior proceedings. Because the Hanford Hospital matter was not final (as the lawsuit against Central Valley was still being contested in Superior Court), the Selma Board had erroneously ruled that the Judicial Review Committee could not substantively challenge, and was obligated to accept the Hanford Hospitals’ findings as true.
The primary implication of Smith is that a peer review body should evaluate outside information and review the provider’s practice at its health care organization(s) to determine whether similar behavior, or practice, might occur, and then consider corrective action.
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From Prevention to Preemption: A Paradigm Shift in Psychiatry
Source: Psychiatric Times
Date: 08/01/2008
Research has shown that preventive approaches in psychiatry can improve behavioral outcomes. In other fields of medicine, similar preventive approaches have reduced deaths from cancer and infectious diseases. However, prevention in psychiatry has done little, if anything, to reduce mortality and morbidity of the most disabling illnesses.
It is worth considering a shift in psychiatric intervention from preventive to “preemptive” approaches. Preemptive interventions target those at greatest risk for mental illness and those with signs of known symptoms, and they provide what has been known as “selective” and “indicated” prevention.
Virtually all mental disorders are chronic disorders. To best meet the challenges of chronic illness, of the utmost importance will be:
1) Understanding patterns of risk that predict disorder for an individual
2) Developing effective interventions for preemption.
Additionally, a trajectory model will be important in this new movement, as chronic disorders can develop for years or even decades before they are diagnosed.
Though currently there are no known biomarkers for early detection of any mental disorder, a number of risk factors for each of the common mental disorders have been identified. In the near or somewhat near future, youths with significant predictors for mental disorder like schizophrenia or bipolar disorder, for example, could be assessed to diagnose the early stages of mental disorder well before a psychotic episode occurs.
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CT scans can be better medicine for doctors than for patients
Source: Los Angeles Times
Date: 09/07/2008
The last half of the century has seen an explosion in the use of computed tomography (CT) scans. Since the 1970s, CT scans have become standard for such common ailments as kidney stones, persistent headaches and appendicitis.
Despite the popularity of CT scans, concern about the effects of the CT scan on patients is rising. CT scans have become the primary driver of the nation’s rising radiation exposure, which can increase an individual’s chances of developing cancer. A controversial study published in the November 2007 the New England Journal of Medicine “estimated that CT scans administered today could cause up to 2% of cancer deaths in two or three decades.”
Most doctors agree that as long as a scan is medically necessary, the benefit in practically all cases outweighs the small future risk of cancer. However, some researchers estimate that up to a third of scans could have been avoided or replaced by safer technologies, such as ultrasound or magnetic resonance imaging. In 2000, Highmark Blue Cross/Blue Shield of Pennsylvania reviewed 162,000 claims for CT scans and other imaging procedures and deemed at least 30% to be either inappropriate or not contributing any useful information.
Doctors have indicated that the pressures of modern medicine, including the fear of lawsuit, have prompted them to recommend more CT scans. Further, there is motivation for doctors to use the machines that bring money to the hospital or practice, especially in a time when medicine is becoming less profitable.
Medicare is now debating how far to go in restricting doctors from referring scanning business to themselves. Starting next year, a common arrangement in which doctors lease blocks of time on somebody else’s machine and bill as if they own the equipment will be eliminated. More significant government interventions, however, are not on the horizon.
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Payer & Reimbursement Issues
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Aetna to Let Outside Doctors Decide on Rescissions
Source: Los Angeles Times
Date: 09/22/2008
The third largest health care insurer in the country will now let outside doctors decide on cancellation of coverage for patients suspected of fraudulently obtaining policies.
Decisions on rescissions will now be referred by Aetna, Inc to three-member physician panels beginning September 22, 2008. Aetna is the first of more than 1,300 insurers to set up binding reviews in every state wherein they do business. The policy shift came about after policy cancellations for patients who had developed cancer and other serious, costly illnesses became a national issue in 2006.
California state regulations have extracted more than $20 million in settlements from insurers regarding this issue. As a result, insurers have either reinstated policies of those denied coverage or altered procedures regarding policy cancellations.
Retroactive policy cancellations, or rescissions, generally occur when companies do not properly check a customer’s eligibility for coverage before issuing a policy. When serious illnesses—such as heart disease or cancer—set in, companies sometimes cancel coverage for the patient, claiming retroactive unsuitability for coverage to save money. This results in extensive healthcare bills and greater debt for patients as well as interruption of treatment.
Aetna has also retained MCMC, an independent review company based out of Boston, to review more than 40,000 medical bills and services per year.
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Experiments in Payment
Source: Hospitals & Health Networks
Date: 09/01/2008
Payment reforms are an important part of the “quiet revolution” in health care that aims to create better health care values and outcome. The reforms address the problems of the current payment system, including the lack of incentive for physician-provider coordination, the dearth of preventive care services, and the need for increased focus on chronic disease. Currently, the different types of payment reform plans are highly varied, and there is minimal coordination among projects.
Reviewed below are five of the most ambitious payment reforms currently working to alleviate heath care payment problems.
-Bundling payments: The plan bundles payments within the medical community to encourage more coordination between providers. Under Medicare’s payment bundling plan, hospitals and physicians would be paid a fixed amount to cover the cost of health care during a “single service unit or episode of care.”
-“Never Event” Nonpayment: On October 1, 2008, hospitals and Medicare beneficiaries will no longer be required to pay for eight “never events,” defined as preventable medical errors that result in serious harm to patients.
-The Prometheus Project: A payment model using financial incentives to encourage providers to follow evidence-based clinical protocols. Under the plan, all health care providers share a payment and must follow clinical guidelines that are graded on quality scorecards.
-Pay-for-performance incentives: A payment model that hopes to improve hospital outcomes and service quality by rewarding hospitals that meet specific quality standards as outlined by a 2003 Medicare reform law.
-Gainsharing: A payment reform plan that aligns incentives for hospitals and physician to encourage efficiency. The Deficit Reduction Act of 2005 mandated CMS to establish a three-year demonstration program to test arrangement programs between hospitals and physicians, but a launch date has yet to be announced.
These reform plans are far from perfect, however, and one area that is not addressed sufficiently is chronic disease care. Critics also point out that CMS does not have a good record of following through on successful pilot programs. Nonetheless, the reforms are a step in the right direction and are already having significant impact in the industry.
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Credentialing, Licensure, Quality Management
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Avoiding Quality Fraud
Source: Trustee Magazine
Date: 09/01/2008
Hospital boards of trustees need to concern themselves with quality of care not only because it is central to the hospital mission but also because failure to do so can be considered fraud.
The Medicare program has penalized hospitals for quality failures since its inception. The Medicare provider agreement’s terms of participation include quality requirements. The Department of Health and Human Services can—and does—drop hospitals from the program for failing to meet quality standards. Though it is rare, use of this severe penalty is increasing.
Additionally, there are significant civil money penalty statutes related to quality failures. These laws involve stiff fines and present a serious threat to boards of trustees, as they do not require the government to meet the criminal burden of proof.
Quality fraud enforcers like the Office of the Inspector General and the Department of Justice are becoming more aggressive. The government has targeted quality failures as false claims cases. Poor quality of care is depicted as a failure to provide the promised and expected level of care, and is therefore a false claim. If a statement made to secure reimbursement contains an inaccuracy, it can be considered a false claim. Even if there is no indication of intent to deceive, intent can be inferred from reckless disregard or a pattern of behavior that includes repeated inaccuracies.
Besides false claims, potential fraud pitfalls include:
-False statements in support of false claims
-Inconsistencies in quality data submitted by different people in the same organization
-Neglecting to report unfavorable data.
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Courts Examine Peer Review: Maintaining a Proper Sense of Balance
Source: American Medical News
Date: 09/29/2008
Congress passed the Health Care Quality Improvement Act of 1986 (HCQIA) with the intention of promoting physician participation in peer review by granting confidentiality and immunity from liability for money damages to those who conduct reviews in good faith. In addition, all 50 states, on top of their immunity laws, recognize a privilege that generally protects information generated during the review process from discovery during unrelated litigation, such as medical liability cases. Nonetheless, peer review issues still make their way into court.
Recent cases have affirmed the protections, maintaining strongly the protections associated with peer review and asserting that doctors shouldn’t be chilled from conducting honest peer reviews. However, some doctors and legal experts believe courts have gone beyond the intent of federal immunity standards by failing to consider potentially malicious intent.
Peer review confidentiality safeguards will not necessarily be protected in courts. The right of the court to unveil private, sensitive information may cause some doctors to be unwilling to participate in peer review in the future.
Laws regarding peer review privacy privileges vary greatly from state to state. AMA policy supports peer review confidentiality and advocates for federal legislation that would prohibit the discovery of records related to such proceedings.
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HHS Site Invites Public to Compare Mortality Rates at 4,700 Hospitals
Source: American Medical News
Date: 09/29/2008
The Department of Health and Human Services recently added data reporting hospitals’ mortality outcomes for heart attack, heart failure and pneumonia to its Hospital Compare website.
These new mortality metrics offer outcomes data, while the previously published data on Hospital Compare only included process measures. Process measures are less controversial than outcomes metrics because such process measures look only at whether clinically recommended care was delivered. Studies have found, however, that using process measures as a proxy for outcomes is problematic.
Government officials and patient-safety advocates want the new information to help patients make medical decisions and spur hospitals and physicians to make systemic changes to lower their patient death rates. By measuring 30-day mortality, as opposed to in-hospital mortality, HHS is seeking to encourage better discharge planning and communication with long-term-care facilities and primary care physicians.
Some doctors argue that this type of reporting will have little effect, if any, on patient care.
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Doctors and the DEA
Source: Government Health IT
Date: 09/26/2008
Current federal directives present a conflict for e-prescribing. The recently passed Medicare bill contains a provision that gives incentives to doctors who use e-prescribing for Medicare patients and penalizes doctors who don’t. Doctors who adopt e-prescribing get a 2 percent bonus in 2009 and 2010 while those who don’t use the technology face fee reductions.
However, the Drug Enforcement Administration (DEA) prohibits e-prescribing of controlled substances, which applies to about 10 percent of all prescriptions. Physicians who use e-prescribing must also maintain a paper-and-fax-based system for controlled substances. The system necessitated by DEA’s rule is inconvenient and some believe it presents an impediment to widespread adoption of e-prescribing.
E-prescribing seeks to boost patient safety by replacing handwritten, and sometimes illegible, prescriptions with electronic ones, which would also enable an automated check on drug interactions and allergic reactions. Only a small portion of the country’s physicians use e-prescribing, but estimates indicate that a major increase in use will occur by the end of the year.
The DEA’s desire to strictly regulate prescription of controlled substances means the agency has been resistant to change. However, in December 2007, officials agreed to set a timetable for revising the federal rules. In June, the agency proposed new rules that would permit e-prescribing of controlled substances under certain conditions. DEA is expected to issue final rules, with or without modification, later this year or early next year.
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Physician Practice Management
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Financial Planning for New Physicians
Source: Minnesota Medicine
Date: 08/01/2008
Amid a flurry of changes and new decisions, new physicians often overlook important financial concerns. New doctors typically carry significant educational debt and so center their financial planning on paying off student loans. However, though their focus may be on debt reduction, in many cases it is prudent to concentrate on other financial goals.
Because interest rates on student loans are lower today than they were decades ago, financial advisors believe paying off debt does not have the urgency it once had. Other financial goals may be more pressing and may reap more benefits for the physician than paying off low-interest debt.
For all new physicians, the best way to attain financial independence is to be frugal. Though it may be tempting to spend freely after years of living on a student budget, living below their means allows young physicians to devote more of their income to savings and investments.
Besides paying off loans and saving for retirement, there are several other key components to building a solid financial foundation:
-Saving for Emergencies
-Purchasing Life Insurance
-Purchasing Disability Insurance
-Funding College Education
-Estate Planning (especially for new physicians who have dependent children)
New physicians who take these steps demonstrate proactive concern to ensure a brighter financial future as they begin their medical practice.
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PHRs Are Coming: Is Your Practice Ready?
Source: Medical Economics
Date: 09/05/2008
A growing number of practices are adopting personal health record (PHR) management systems. PHR systems can integrate with electronic health record (EHR) systems to allow patients to upload medical information into a personal health record and view records kept by their doctors. The PHR system facilitates communication between doctors and patients.
Currently, only about 2.7% of all U.S. adults have PHRs. The main concern among those who don’t have them is the privacy and protection of medical information. Privacy protocols are being developed, though: on June 25, 2008, PHR providers Google, Microsoft, WebMD and Dossia, as well as 27 healthcare providers, insurers and consumer groups, agreed to a set of guidelines on how to protect medical information and how it will be shared.
Benefits of PHRs:
-Availability of the most current and accurate information on patient medication, allergies, etc. in one location
-Improved communication with patients, especially those with health-monitoring devices
-Ability to share lab test results with patients online
-Efficiency, serving as a great time-management tool for physicians
-Portability: PHRs can go wherever the patient may travel or relocate, making a practice especially attractive if its office’s EHR system is compatible.
Drawbacks of PHRs:
-Financial downside: there is no reimbursement mechanism in place to compensate doctors for the time spent reviewing PHR information
-No industry standard yet to integrate PHRs with practice EHR systems
-PHRs work only if patients take time to—and know how to—update their records.
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Retail Health Clinics: How Your Practice Can Compete
Source: Medical Economics
Date: 09/19/2008
In August 2008, the 1,000th retail health clinic in the United States opened, just eight years after the opening of the first. Some physicians and hospital emergency departments worry that retail clinics are chipping away at their earnings by luring patients away for quick, reimbursable treatments. Physician practices maintain an advantage, however, in that survey results confirm that doctors are still the most trusted source for information about health conditions and treatment, and many consumers report they would not be comfortable with the care offered in a retail clinic.
More than 65 percent of retail clinics are located in drug stores and are typically either breaking even or losing money for their parent company, according to Deloitte. Retailers view them as loss leaders that allow them to sell more drugs—prescription and over-the-counter—as well as other consumer goods. Surprisingly, the main appeal of the clinics is not the low price. Most consumers surveyed by Deloitte who had used a retail clinic indicated they would pay an out-of-pocket cost as much as $80 per visit for the benefit of having hours and location that fit their lifestyle.
Experts believe that physician practices can remain competitive by expanding and altering their hours of operation. Rather than compete, some physician practices are partnering with local retail clinics, but these practices do not represent the preferences of the majority. In addition to adding locations and extending hours, continuing to provide the highest quality of care will not only allow practices to stay competitive but also may distinguish them from the clinics.
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