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Stem cell research is definitely in the news. A recent ABCnews.com story spotlighted an injured policeman in Texas who regained physical strength and mobility as a result of adult stem cell injections he received in China. (Click here for the online video.) Despite the actual and potential benefits of stem cell research, many healthcare professionals disagree on key issues related to its advancement and practical application. Our survey frames the debate from several different perspectives. More…
Pushing the limits of medical research |
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Stem cell research is like universal health care. Almost everyone has an opinion about it, but sometimes the debate generates more heat than light. Most proponents view stem cell research as a tremendous boon to medical technology that can prolong lives, reverse congenital diseases, restore damaged tissue, and actually regenerate lost limbs.
In fact, the Pentagon recently announced a massive project, budgeted at $250 million, to advance stem cell research specifically aimed at harvesting cells from military personnel prior to their being deployed into war-torn areas. The expectation is that upon their return, any service person that has experienced physical injury or trauma could receive restorative medical treatment derived from their own harvested stem cells. It remains to be seen how quickly or effectively that research initiative will pay off.
The actual or potential benefits of stem cell research notwithstanding, serious questions remain.
This month’s survey, “The Stem Cell Research Debate,” sheds some light on the ongoing, often-polarizing debate. Particularly noteworthy are the comments of respondents who have strong opinions on the subject. In complementary fashion, our Special Report, “Embryonic Stem Cell Research—Promise and Controversy,” addresses other concerns that are being discussed by persons knowledgeable of the issues.
As always, the Jackson & Coker Industry Report spotlights the critically important issues voiced by different sectors of the healthcare community. Informed readers can draw their own conclusions.
Cordially,
Calvin Bruce
Managing Editor
‘Robodoc’ Coming to a Hospital Near You
Source: San Diego Union-Tribune
Date: 08/14/2008
“Remote-presence robots,” wireless human-sized computers capable of transmitting voice and video data over long distances and controlled remotely by joysticks, are the latest approaches to the field of telemedicine, enabling doctors to evaluate patients from afar. At Pomerado Hospital in North County, CA, one such robot is employed by Dr. Ben Kanter to check on patients and to chat with patients’ family members, usually accompanied by a nurse. These robots first appeared in 2002, and the technology is now on its seventh generation. The robot is on lease from Santa Barbara-based InTouch Health and is one of 200 in use globally according to the company.
Remote-presence robots are no substitute for doctors, Dr. Kanter points out, but can greatly enhance patient care. For example, a doctor at a children’s hospital may evaluate patients at other hospitals, assessing the need for transfer and recommending appropriate treatment. Hospitals without specialists on staff will find the technology useful as it enables specialists from distant hospitals to quickly evaluate patients and consult with doctors on-site.
Regarding telemedicine in general, new medical education facilities are being built, equipped to train medical students in the field. Doctors, nurses, and patients alike are impressed with the new technology and have expressed interest in working with remote-presence robots.
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Opinion: Is There Really a Physician Shortage?
Source: Contemporary OB/GYN
Date: 08/01/2008
With the AAMC calling for a 30% increase in medical school admissions, numerous states accrediting new medical colleges, and numerous state, federal, and industry organizations predicting shortfalls of anywhere from 80,000 to 200,000 physicians over the next fifteen years, the consensus seems clear: America faces a physician shortage which will only get worse with time. But how reliable is this consensus? An article in Contemporary OB/GYN examines the underlying evidence and posits a different conclusion.
The author questions the need of even the current medical workforce. Citing stats indicating a climb in per capita physician populations of 47% from 2001 to 2010, the author says the current shortage is really more of a distribution disparity. In the past two decades, non-metro areas have had higher proportional growth in per capita physicians than have metro areas. The author states that this deficiency does not lead to adequate care, citing patient satisfaction surveys and Medicare composite quality scores indicating that per capita physician populations have little effect on quality of care. Further, he notes that rural areas have the best ratios of generalists to specialists.
The author blames the shortage fears on specialty societies, whose connections to trade unions, in addition to public health concerns, lead to simplistic models of physician need adjusted for projected demographic trends. Further, the projections do not take into account the cloud of physician extenders currently saturating the marketplace.
In general, the author says that concerns about a physician shortage are overblown generally and could lead to unsustainable programs, as the requested increases in enrollments and residencies will necessitate state and federal funding, and he predicts an increased physician supply will actually drive up the costs of healthcare. The author concludes that the solution is a comprehensive plan for health care access coupled with efforts to undo the disorganized and fragmented delivery system that is really at the heart of the “shortage.”
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CMS Finalizes Stark Rule Changes in Final 2009 Inpatient PPS Rule
Source: Mondaq.com
Date: 08/14/2008
The Centers for Medicaid and Medicare Services released its final 2008 inpatient PPS rule on July 31, 2008. The rule includes important revisions to the Stark Regulations, including finalized revisions to the Physician’s “Stand in the Shoes” provisions and proposals to restrict “under arrangements” transactions, per unit space/equipment lease transactions, and percentage based compensation arrangements, among other regulatory aspects.
-Physician “Stand in the Shoes” provisions—The final rule provides that SITS does not apply to arrangements satisfying the Academic Medical Center Exception.
-Per Unit/Percentage of Revenue Leases—CMS clarified that prohibitions on “click” fees are not limited to space/equipment leases between physician-owned leasing companies and DHS entities. CMS also finalized its prohibition on percentage based compensation in space and equipment leases.
-Set in Advance Requirement—CMS’ new position is that amendments to compensation terms between a DHS entity and a physician or physician organization will not cause the agreement to fail the Set-in-Advance requirement if it fits the necessary criteria detailed further in the rule.
-Alternative Exception for Obstetrical Malpractice Insurance Subsidies—This exception protects the subsidy paid by a hospital, federally qualified health center or rural health clinic if ten requirements are met, including the requirement that the physician's medical practice is located in a primary care Health Professional Shortage Area.
-The new ruling places the burden of proof in appeals of Stark-based payment denials on the entity appealing the denial.
-Disclosure of Financial Relationships Report (DFRR)— The final rule announces that CMS is proceeding with its proposal to send the DFRR to 500 hospitals.
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N.J.’s Biggest Insurer May Turn For-Profit
Source: Philadelphia Inquirer
Date: 08/16/2008
Horizon Blue Cross Blue Shield has filed for a move that could turn the New Jersey healthcare giant for-profit. The company is New Jersey’s largest healthcare payer, covering fully 40% of New Jersey residents. The conversion is expected to add a billion dollar windfall to the state budget. This influx of cash would go to funding a charity to serve the underserved in New Jersey’s population.
Proponents of the proposed status alteration for Horizon say that the for-profit model will maximize operational efficiency and possibly result in lower cost coverage to residents. Opponents predict that the company’s priorities will shift immediately from customers and employers to future shareholders.
Non-profit payers generally convert to for-profit when they are looking to expand. Some fear that a merger with another company would shift Horizon’s focus from New Jersey residents to larger markets. Horizon took in $7.5 billion in revenue in 2007, of which $2.5 billion was from for-profit subsidiaries.
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22% of Americans Surveyed Cut Visits to Doctor
Source: San Francisco Chronicle
Date: 08/13/2008
Nearly one in four Americans have reduced the number of times they’ve gone to see the doctor in order to save money, according to a new poll by the National Association of Insurance Commissioners.
The poll, which surveyed 686 consumers in July of 2008, found that 22% of respondents had lessened their trips to the doctor in response to the economy. Furthermore, 11% said they had dropped prescriptions or changed dosages to make the drugs that they did have last longer.
These behaviors likely arise from the national trend of health care costs—typically handled through an employer-based system—with more and more being shifted onto employees. As employees are forced to pay more, their healthcare behaviors are changing to compensate. Officials are concerned that initially manageable conditions may become serious due to neglect.
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Physicians’ Right of Conscience
Source: The Examiner
Date: 08/12/2008
Secretary of Health and Human Services Mike Leavitt is in the news again for comments on whether physicians should be required to refer patients to other physicians in a timely manner when the patient’s interest in contraception or abortion conflicts with the physician’s own values. Leavitt questions the American College of Obstetricians and Gynecologists’ (ACOG) perceived desire to take away physicians’ “right of conscience,” which would allow them to refuse to participate in any medical practice they consider a matter of conscience and has drafted new federal laws to protect this right.
In November of last year, the ACOG’s Ethics Committee released a statement advising OB/GYNs that they have a duty to refer patients when a conflict of values prevents the desired care.
Leavitt’s latest comments in an August blog post have provoked strong reactions. According to Leavitt’s post:
This is not a discussion about the rights of a woman to get an abortion. The courts have long ago identified that right and continue to define its limits…This is about the right of a doctor to not participate if he or she chooses for reasons they consider a matter of conscience….Is the fear here that so many doctors will refuse that it will somehow make it difficult for a woman to get an abortion? That hasn’t happened, but what if it did? Wouldn’t that be an important and legitimate social statement?
Noting that HHS has yet to make a final decision on the matter, Leavitt emphasized that taking into account a physician’s right of conscience is something that all members of the health profession should respect.
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A Decline in Uninsured is Reported for 2007
Source: New York Times
Date: 08/26/2008
The number of Americans without health insurance dropped by a million in 2007 to 45.7 million according to new numbers out from the Census Bureau.
The drop comes from a growth in the rolls of those covered by government health insurance programs. The number of people covered privately continued to decline.
The Census Bureau’s report does not take the recent economic downturn into account, critics counter. It also, advocates for the poor contend, presents an outdated idea of what constitutes health care coverage.
Government officials say that the numbers are indicative of federal programs offsetting the drop in private coverage. The percentage of people covered by the government rose to 27.8% in 2007. The percentage of people covered by Medicaid rose to 13.2%, while the percentage of people covered by private health insurance fell to 67.5%, with employment-based insurance coverage falling to 59.3%.
Conservative groups cite the decreasing wages of Hispanic and black Americans as the most newsworthy statistics. Those households have shown significant drops in income, which likely significantly impacted their ability to attain private coverage, even with the assistance of an employer.
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Industry Insider: Etiquette tops patients’ checklist
Source: The Star-Ledger
Date: 08/12/2008
The American Board of Medical Specialties, the nonprofit organization that oversees the board certification of U.S medical specialists, recently surveyed approximately 1,000 adults to identify the physician qualities most desirable to patients.
Physician communication and bedside manner was ranked as important by 95% of all respondents. The majority of survey respondents also found board certification to be a highly important physician quality, but only 45% had ever checked to see if a doctor was board certified.
Responses to the survey indicate that many survey respondents lack information regarding a number of facets of the medical process, from the process of board certification to doctor qualifications. The majority of respondents noted that they didn’t understand what board certification entailed or meant for physicians, and 60% of respondents incorrectly believed that a doctor had to be board certified to practice medicine.
This lack of information on the side of the patient may be due in part to the fact that 57% of the survey respondents reported that they find it difficult to locate useful and clear information on doctors. Additionally, only 31% of respondents said that they ask questions about a doctor’s qualifications, and only 28% of respondents had researched a doctor’s qualifications prior to making an appointment.
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Sign In and Pay Now: Insured Patients Finding They Must Put Down Higher Fees Upfront for Care
Source: South Florida Sentinel
Date: 08/26/2008
It’s usually a set process: see the doctor, get a bill later. So why are an increasing number of patients around the nation being asked to pay some money upfront?
It’s part of a larger national trend of hospitals asking more upfront from patients, with elective or scheduled procedures now eligible for withholding dependent on the patient’s ability to pay. An informal survey of southern Florida hospitals found all of them requiring upfront payments for elective surgeries, and as insurance companies require higher payments, upfront requests at hospitals go higher and higher.
Health insurance premiums are up 78% from 2001 to 2007. Employers continue to cut back benefits or ask employees to contribute more. Hospitals argue that the higher costs go hand-in-hand with higher risks on their part, necessitating the upfront payments. State hospitals spent $2.4 billion on uncompensated care in 2006, up 73% from 2000. As a result, the IRS says that 14% of 481 nonprofit hospitals nationwide require payment or agreement on a payment plan before admittance.
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Stanford to Limit Drug Maker Financing
Source: New York Times
Date: 08/25/2008
Concerned about the influence of drug companies on medical education, Stanford has announced restrictions on industry financing of continuing medical education at its medical school.
While it is common for pharmaceutical companies to fund CME courses, critics claim that they only fund classes that are pushing their latest product. As a response, Stanford no longer allows for pharmaceutical companies to fund specific courses. Rather, all companies contribute to a pool of money that goes to fund all classes. This makes Stanford the sixth major medical school to do such, joining the Universities of Massachusetts, Pittsburg, Colorado, Kansas, and California-Davis. Industry donations were banned at the Memorial Sloan-Kettering Career Center.
The move is in response to growing scrutiny of industry financing of continuing medical education. A recent investigation found that drug makers were using classes to push their latest products. The investigations seem to have had an effect, causing some pharmaceutical companies to publicize lists of their grant recipients.
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Department Focus—Human Resources: MBAs Among Us
Source: Health Leaders Media
Date: 08/15/2008
With the realm of health care becoming increasingly complex and profit margins—if even extant—getting thinner and thinner with each passing year, some hospitals are abandoning the old practice of hiring recruits with Masters in Hospital Administration for administration positions, seeking instead candidates with greater business acumen. They’re bringing in MBAs for leadership roles.
Such is the case at Houston’s Memorial Hermann Healthcare System, where administrators admit that MHAs tend not to have a full understanding of the market necessities to make healthy decisions for a large hospital. Administrators are beginning to prefer candidates with the ability to look at operational issues and act accordingly.
MBAs also, according to administrators, tend to be more ready for leadership roles more quickly. Administrators still won’t say MBAs are the all-around better candidates for 21st Century hospital administration, but the professed popularity among some hospital leaders hints that this may be the beginning of a trend. Indeed, with the exception of some highly specialized clinical roles, some administrators don’t see any place in particular where an MBA couldn’t fit into hospital administration.
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The Perfect Hospital CEO from Spare Parts
Source: Health Leaders Media
Date: 07/14/2008
In an article in Health Leaders Media, author Jim Molpus does a bit of wishful thinking and comes up with the traits that would make up the perfect Chief Executive for the modern hospital.
Molpus postulates nine traits deemed indispensable in the modern CEO. All of these rolled into one would result in a Chief Executive who was:
-A Servant Leader—A CEO of a hospital should be called to make the institution better above all else, including personal skill development.
-Risk-Taker—Having a CEO willing to take risks, but not gamble recklessly, is a critical asset for the successful hospital of the future.
-Cheap (but not in a bad way)—With today’s razor thin margins looking to get thinner in the future, there’s no room for decadence. CEOs should be level headed and frugal regarding administrative compensation and perks.
-Strong Assistant Coaches—A top-flight senior team is an absolute must. Any CEO who can’t put together a good team should probably start looking for a new line of work.
-Attracts People—The CEO doesn’t need to be overwhelmingly charismatic, but should have a personality that attracts people to follow their lead.
-Rocks the Babies Once in a While—Reaching out to patients can’t help but improve a hospital’s image. Administrators who not only know this but actively practice it as well are indispensable.
-Not Overly Competitive—Being driven is one thing, but winning should always have a purpose. Single-minded pursuit of victory for victory’s sake can result in a loss of sight of what is really important in a hospital: the patients.
-Holds Everyone Accountable—Setting a bar for high achievement should include doctors as well as middle managers.
-Looks Outside—The CEO should remain aware of what’s going on outside the hospital and work to balance the hospital’s needs and the demands of the larger industry and the community at large.
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Employment & Compensation
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Partnership: Don’t Let Your Partner Conflict Destroy Your Practice
Source: Physicians Practice
Date: 08/01/2008
Internal practice conflicts can have devastating results for a practice. Conflicts between physicians can arise from disagreements over behavior, compensation, or any number of other issues. Such conflicts can severely damage the functioning of a practice, but an article in Physician Practice reveals some methods of making sure they don’t pop up in the first place.
Make sure all sides declare their expectations regarding employment at the beginning. Most partnership agreements don’t specify a number of patients to be seen per month or the amount of call expected. It is hard to get these set in stone, but it is important for at least an informal declaration of expectations on both sides, so that no party feels like he is getting a raw deal from the arrangement.
The division of income and patients is a major source of conflicts. In practices with a healthy group dynamic, equal division of income and patient load may work well. Expenses like rent and utilities should be split evenly if possible. Another good way of income division is division based explicitly off productivity.
Beware of employing spouses, as that is generally a bad idea. Employing spouses opens the door to the unenviable necessity of disciplining or correcting a colleague’s spouse.
Avoid the urge to become “the great dictator” of your practice. People need to be able to confront senior physicians and partners.
Deal with behavioral problems. Whether it’s a sassy administrative aide or a hot-shot rainmaker physician, difficult-to-deal-with employees should be dealt with according to an equitably enforced code of conduct.
Finally, formalize decisions through votes and committees sized appropriately to the size of your practice. People are less likely to go against decisions if they feel that they were made by group consent. It is thus easier to keep physicians in line and cooperative, especially if they feel they have had some voice in the formulation of policy.
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Forming a Legitimate Physician-Hospital Alliance
Source: HHNMag.com
Date: 08/12/2008
Physician-hospital alliances, while something of an increasing trend on the national scene, are often barred by Federal Trade Commission antitrust regulations, but some organizations may have found ways to integrate with the approval of the FTC.
Cooperative efforts should be structured to ensure that they are not inherently anti-competitive in order to not risk raising regulatory ire, and clinical integration efforts should show a desire to gain efficiencies and hold down costs, resulting in improved outcomes and benefits for patients. To avoid charges of price fixing, cost arrangements must be simply a means by which efficiencies and patient benefits can be achieved, not an anti-competitive measure. Networks failing at this have been the ones with collective fees not reasonably necessary to achieving any efficiency-enhancing integrations.
One manner of avoiding legal complications is to seek an advisory opinion directly from the FTC. Such a path was undertaken by MedSouth in 2002 and Suburban Health Organization in 2006. MedSouth received a go-ahead on their plans, while SHO was informed that their scheme would be in violation of FTC regulations. While the SHO decision may seem like a setback, the denial likely saved the organization much time, trouble, and money in the way of legal troubles.
Another example of a successful implementation of clinical integration relates to the Greater Rochester Independent Practice Association (GRIPA). After a request to the FTC for an advisory opinion, the organization proposed the sale of its participating physicians’ services to health plans on a fee-for-service basis. Physicians would still remain free to negotiate and contract separately with plans and patients that did not wish to participate in the GRIPA services. The FTC judged the partnership to have the potential to achieve significant efficiencies and the price controls to be subordinate to the program’s primary goals, thus avoiding charges of price-fixing.
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Many Changes in Store as Physicians Become Employees
Source: Managed Care Magazine
Date: 07/01/2008
The American healthcare delivery system is undergoing a period of rapid change. One area increasingly affected by the shifts in health care is the physician employment model. An article in Managed Care Magazine explores the rearrangements under way in American healthcare and looks at the causes and likely outcomes.
An important current trend is the employment of physicians by hospitals. In attempts to move past the disastrous practice acquisitions of the nineties, a period of rapid physician-hospital integration is currently taking place, with specialists seeking out employment at hospitals. This is largely an outgrowth of demographic, financial, and physician-personal trends.
Employment with a hospital generally means more freedom to focus on the practice of medicine, which is what today’s doctors, leery of administrative tasks and haggling with insurance companies, are more likely to want. Furthermore, with reimbursement rates not keeping pace with practice costs, employment with a hospital and taking refuge under the institution’s collective financial umbrella makes sense for doctors wanting to practice medicine but rebuffed by the costs of private practice.
As a result, hospitals are paying less to acquire practices than they did in the nineties, with physicians joining up even if they are not paid for their practice. Physicians typically join hospitals on a payment plan tied to revenue generation, where physician productivity drives institutional profitability.
Insurers also reap some benefits from this trend. Physicians and hospitals working together means generally better and more integrated care, plus increases in overall efficiencies. Hospitals are also more likely to make the necessary investments in efficiency-increasing information technology upgrades such as electronic health records and prescriptions. Furthermore, more physicians gathered into fewer places means fewer points of contact for companies, saving both sides administrative hassle.
Some experts predict that this trend will continue and envision an end state of very few small private practices, while many physicians are employed with hospitals. The remainder of physicians would be part of a multispecialty model that would offer ancillary services and control the referral system.
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Work Hours Found to Create Little Respite for Residents
Source: American Medical News
Date: 09/01/2008
The time-devouring, exhausting rounds of residents are little relieved by imposed work hour limits, this according to a study released by the journal Pediatrics.
The study of 220 residents at three pediatric hospitals found that total work and sleep hours did not change after the Accreditation Council for Graduate Medical Education (ACGME) set limits of 24 to 30 hours per shift and 80 hours per week in 2003.
The study also found no change in the rates of medical errors or resident depression and injuries. Previous studies have found that the risk of medical error or physician injury increases dramatically after 16 hours of work.
ACGME, for its part, counters that the data in Pediatrics is old. The organization cites its own study from 2006-7 indicating that 94% of the 58,602 surveyed residents said they always or usually met the recommended hourly limits. They also cite increased noncompliance citations as further evidence of corrective action. By contrast, the data in the study from Pediatrics is from 2003 and 2004.
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Legislation Would Protect Physicians Who Volunteer to Treat Low-Income, Uninsured Patients From Liability Claims
Source: Medical News Today
Date: 08/07/2008
In the hopes of encouraging physicians and other members of the medical community to volunteer at clinics and community health centers, Senate Health, Education, Labor and Pensions Committee ranking member Mike Enzi (R-WY.) recently introduced the Volunteer Health Care Program Act, which would provide states with grants to be used to assume partial medical risk liability for physicians and ensure that patients can recover damages from medical malpractice.
The bill is particularly focused on recently retired medical professionals who no longer have medical liability insurance, and are thus discouraged from providing voluntary services due to the potential costs of medical malpractice suits.
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Bill Would Let Troops Sue for Malpractice
Source: Army Times
Date: 05/27/2008
Named for a Marine sergeant who is claimed to have died from skin cancer after a series of mistakes by military medical personnel, the Carmelo Rodriquez Military Medical Accountability Act would let service members sue the military for medical malpractice.
The bill was introduced by Maurice Hinchey (D – NY) and co-sponsored by Bob Filner (D-CA) and the House Veterans Affairs Committee chairman Barney Frank (D-MA) in order to reverse the Feres Doctrine, a 1950 Supreme Court ruling prohibiting lawsuits for medical malpractice that harms service members.
Lawmakers have proved themselves to be reluctant to support attempts to reverse the policy, which defense officials claim is essential to keep qualified medical professionals in the services and to protect military rank structure.
The accountability act would allow claims for damages for death or personal injury resulting from negligence, the failure to act, and wrongful acts in medical, dental or other health care services provided to military service members. All claims would be brought against the government instead of military doctors.
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Surgical Specialty Seeks More Women
Source: Chicago Tribune
Date: 08/14/2008
Despite more than half of all US medical students being female, the Journal of Neurosurgery reports a potential shortage of neurosurgeons over the next few years due to a lack of females entering the profession.
Female board certified neurosurgeons account for less than 6% of the neurosurgery workforce and less than 5% of neurosurgeons in private practice. With only 2% of graduating medical school students applying for 180 available neurosurgery positions, experts in the field claim there is an urgent need to be filled. Neurosurgery, they say, faces a decreasing population even as the medical field increases in size.
To bring in women, medical schools and teaching hospitals need more women in leadership positions, experts in the field say. Women should take up more positions as faculty and department heads in addition to other leadership fields.
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The Hospitalist Teacher
Source: acponline.org
Date: 08/01/2008
As hospitalists are increasingly used in academic departments, they are more and more responsible for the overseeing of daily patient care and a number of other tasks. How to balance all of the duties of the hospitalist and at the same time effectively educate students and staff? A model currently in practice at the University of Colorado/Denver VA Medical Center may hold some answers.
With this model, teams consist of an attending physician, a second-year resident, two interns, two third-year medical students, and a fourth-year student or sub-intern. The process consists of the following steps:
-Prerounding: In this step, house staff and students see patients before attending rounds, gathering information necessary for clinical decision making. Each trainee constructs an independent assessment and plan from prerounding. It is believed that learners are encouraged by this to interpret data and make their own guesses as to diagnoses or management.
-Team rounds: The entire team gives a patient-focused presentation at a certain time each day. The presentation ends with the student’s assessment of the patient. The hospitalist, during the presentation, verifies physical findings and observes the skills of the trainee, acknowledging well-done jobs or providing constructive criticism for areas needing improvement.
-Q&A: The student, intern, and supervising resident respond to the hospitalist’s questions, which have the intent of clarifying the clinical assessment.
-Wrap-Up: The team and patient come to agreement on the plans for the day and the patient’s family gets their questions answered.
It is believed that the structured format teaches all involved of the necessity of obtaining all required clinical data. The rounds do not function as a replacement for teaching sessions, but do allow for expanded teaching outside the confines of the conference room.
Hang-ups with the process include patient comfort at open discussion of medical information and possible anxiety of hospitalists regarding the model. In all, though, the model has worked quite well in practice and appears to result in greater participant learning and improvement of teaching skills as well.
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Collaborating With Our Medical Colleagues
Source: Psychiatric Times
Date: 08/01/2008
Each medical area is different, but none to the extent that services, billing, and record-keeping for each area should be fully separate. Problems can arise when a patient manifests both psychiatric and physical medical conditions, because the system as it stands is not integrated. A psychiatrist, for example, may prescribe an anti-psychotic to a patient. The patient later proceeds to a doctor’s office for treatment of a physical ailment, and because patient records are not shared between medical doctors and psychiatrists, the doctor prescribes a medication counter-indicated for the anti-psychotic, and the patient suffers.
Non-psychiatric physicians may have trouble visualizing a world in which they collaborate with psychiatrists because tradition has kept them in separate domains. Psychiatrists as well may resist the idea, as many psychiatrists argue that psychiatric disorders require special privacy laws, preventing the flow of patient information between parties.
However, physical and psychiatric services could be disintegrated with great benefit to the patient. Because mental health and substance abuse disorders unsurprisingly lead to a deterioration of physical health, it would benefit the patient if non-psychiatric physicians and psychiatrists collaborated on plans for treatment. In fact, there is mounting evidence of the necessity of non-psychiatric and psychiatric services to be combined, in order to prevent patients from being harmed inadvertently by the health care system.
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Urgent Care: Locum Tenens Professionals Fill the Gap
Source: LocumLife
Date: 08/15/2008
Urgent Care Centers serve a growing demand nationwide. With their numbers estimated at more than 10,000 centers nationally, these centers offer cheaper and faster services than do many Emergency Rooms. They also provide a tremendous opportunity for locum tenens professionals.
Locum tenens professionals with experience in urgent care or ambulatory medicine, emergency medicine, internal medicine, and pediatrics are increasingly finding a place in urgent care centers. They take the place of other temporary physicians while clinics fill their staff vacancies through recruitment, or they just shore up staff numbers for institutional seasonal requirements. They come from a variety of backgrounds and typically make between $140,000 and $180,000 a year.
Urgent care specialists interested in practicing locum tenens should be certified in family practice or emergency medicine or double boarded in internal and pediatric medicine. Basic Life Support, Advanced Cardiac Life Support, and Pediatric Advanced Life Support certifications are all recommended.
Urgent care clinics will likely see growth in demand as the population increases, meaning more opportunities for interested and qualified physicians. Before accepting contracts, though, it is recommended that a physician consult with a longtime or long-term physician on site to get a feel for the work environment. If the job fits, it can result in an assignment or even a career that one didn’t even know one was suited for previously.
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Medicare Pays Out $36M for PQRI; Only 16% of Eligible Radiologists Partake
Source: Health Imaging News
Date: 07/18/2008
The 56,700 health professionals participating in the CMS’ Physician Quality Reporting Initiative should receive bonus payments through August, averaging over $600 per physician and totaling $36 million in payments for the whole program.
According to the American College of Radiology, only 16% of eligible radiologists participated in the PQRI program, comparable to the 17% of eligible clinicians that participated.
The PQRI was established by Congress in 2006 and is part of a move toward performance-based payment by CMS for health care services. The PQRI bonus payments are capped at 1.5% of a physician’s total allowed Medicare charges. Related to this, physicians in Florida and Illinois have allegedly received the most bonus payments.
CMS has also made PQRI data available in a format that allows physicians to compare performance with others participating in the program.
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Payer & Reimbursement Issues
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Medicare Plans E-prescribing Conference, Seeks Cosponsors
Source: Healthcare IT News
Date: 08/11/2008
The Centers of Medicare & Medicaid Services is planning a conference for October 2008 that will educate physicians and other stakeholders about a federal incentive program to encourage the use of e-prescribing systems.
Scheduled to begin January 1, 2009, the incentive program is based on legislation that characterized “successful prescribers” as those that use e-prescribing measures established by the Physician Quality Report Initiative or submit prescriptions electronically under Medicare Part D. The October e-prescribing incentive program conference aims to:
-Educate healthcare professions and stakeholders about ways to integrate e-prescribing into their business model.
-Review the structure and implementation of the incentive payment structure regarding e-prescribing and PQRI.
-Discuss the use of e-prescribing and other e-health initiatives to increase patient compliance and health.
-Identify and review solutions to barriers regarding the adoption of e-prescribing technology.
-Address concerns about privacy, security and risk-management regarding the incentive program.
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Getting What You’re Owed by Third-Party Payers
Source: Medical Economics
Date: 08/15/2008
Despite legal decisions and coordinated efforts by doctors’ groups, physicians still encounter numerous obstacles in trying to get the full compensation they’re due from payers. An article in Medical Economics examines methods of ensuring proper payment is procured.
The article arises from the 2008 Annual Meeting of the National Society of Certified Healthcare Business Consultants. In describing claim denial equations, forging relationships, and negotiating contract terms, among other things, the panel hit upon a number of techniques to best ensure compensation:
-Fight back when plans don’t play by the rules. If a claim is rejected more than once in spite of clear evidence supporting the physician, take the case to the state insurance commissioner. If the payer continues to fight you there, think of the ultimate cost to your practice if you give up, and continue fighting back until they pay fully.
-Don’t be put off by stalling tactics. Respond right away to requests to clarify information on claims. Dates and codes are important, and attention to detail is essential. All members of your staff should know this.
-Forge relationships to boost the bottom line. The panel recommends sticking your nicest, most professional staff member in the position of insurance industry contact. Keep a record of the most helpful contacts on the payer side your practice has encountered and get as much information out of them as possible whenever possible. Maintain a good relationship with them and it will pay dividends.
-Get the facts before you negotiate. Pick 20 to 30 codes that represent 75-80% of your charges. Prepare reimbursement analyses for these codes to take with you into any negotiations. Also, use a consultant to figure out how your compensation rate compares to others’.
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Trying to Save by Increasing Doctors’ Fees
Source: New York Times
Date: 07/21/2008
Across the country, federal and state agencies and many insurers are attempting to decrease health costs by incentivizing family physicians, internists and pediatricians with higher payment. The idea behind the incentive is that doctors will increase the amount of attention and time they spend on patients, and consequently increase the quality and effectiveness of care.
Health policy experts say that the current Medicare and commercial insurer doctor payment per primary-care doctor visit, which averages at about $60, is not enough to incentivize doctors to increase the amount of time they spend with patients. And without an appropriate monetary incentive, doctors often do not spend enough time on careful patient examinations--resulting in a substantial number of Americans with unidentified or under-treated illnesses that often become cost-incurring serious medical conditions.
In order to address the issue, insurers are conducting payment increase experiments involving doctors and almost 2 million payments in at least a half-dozen states. Government programs such as Medicare and Medicaid have implemented similar experiments. A 2006 Medicaid experiment in North Carolina reportedly saved the government $162 million.
Perhaps due to the success of such pilot programs, the Senate overrode President Bush’s veto to authorize $100 million to finance a three-year Medicare experiment to further investigate the health cost effects of spending more on primary care.
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CMS Releases Guide for Navigating Medicare Coverage
Source: Healthcare Finance News
Date: 08/27/2008
Technology innovators now have a new means of navigating Medicare coverage, coding, and payment rules and regulations, according to the Centers for Medicaid and Medicare Services.
The CMS has published a new guide—the Innovator’s Guide to Navigating CMS—which was developed by the Centers’ Council for Technology and Innovation, a group charged with the streamlining of CMS processes to get beneficial and safe technological innovations to providers as quickly as possible.
CMS officials describe the new guide as a one-stop-shop for actionable information and intelligence on CMS. Medicare reserves the right to make explicit coverage and coding changes to ensure the coverage of reasonable and necessary new technologies.
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Credentialing, Licensure, Quality Management
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Delegated Credentialing and Physician Performance Reporting
Source: URAC Issue Brief
Date: 06/01/2008
In response to the competing interests of purchasers and health plans regarding the efficiency and broad accessibility of health care practitioners, the Utilization Review Accreditation Committee (URAC) has proposed revisions to the standards for health plan and health network accreditation.
A summary of the changes highlights delegated credentialing and physician performance reporting as areas needing revision and proposes revisions to the existing standards with regards to gathering and evaluating information about the quality of health networks as well as a new venture regarding the creation of a new standards model.
-Delegated Credentialing—most health plans and networks do in-house credentialing, though some contract with outside vendors to provide these services. Credentialing is, according to URAC, among the top administrative functions outsourced by hospital administrators. URAC has rolled out Credentialing Support Certification, a program directed at international and domestic markets. The program requires credentialing companies to meet standards focusing on non-clinical aspects of credentialing, ensuring the quality of the credentialing services involved. Plans and networks retain the final authority over whether or not to allow participation by providers, but they are assured higher quality credentialing through the proposed service, which would allow for more timely completions of the credentialing process.
-Physician Performance Reporting—URAC is proposing a new standards model to provide a means for accredited organizations to demonstrate transparency in their provider performance benchmarking process. Whereas the current process does not address the need for transparency in health care from a broad base of stakeholders, URAC’s proposal offers a means of broadcasting this transparency for plans or networks that choose to publicly report provider performance benchmarking information, offering a way for organizations to demonstrate that there is transparency in their process.
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Want to Find Out More About Your Doctor?
Source: StarTribune.com
Date: 07/26/2008
The Minnesota Board of Medical Practice’s two-year-old searchable database of complaints against its licensed doctors, established in response to its receipt of over 700 complaints annually, is now more user-friendly than ever. The database was established in light of accusations of lax disciplinary actions taken against doctors, whose transgressions range from over-prescribing narcotics without medical need and sexual misconduct to substance abuse and professional incompetence.
A recent decision by the board to suspend the license of a doctor found to have maintained sexual relationships with two of his patients has health care consumers more anxious than ever to check the background of their physicians.
The board’s executive director, Robert Leach, calls the database “among the more user-friendly databases of doctor records” he has seen. It offers consumers information on a physician’s prior disciplinary actions, education, location of practice, area of specialty, and self-reported criminal convictions.
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Medicaid to Spend $380 Billion on IT, Consulting Firm Estimates
Source: Healthcare IT News
Date: 08/22/2008
State Medicaid programs, according to a new report from business consulting firm INPUT, stand to spend more than a quarter of a trillion dollars on information technology in the coming years.
The spending will arise as a result of the expiration of contracts between state Medicaid Management Information systems and vendors in as many as 21 states, beginning in 2009. The $380 billion will represent nearly 22% of all state spending for the duration.
Representatives from INPUT cite the primitive status of existing Medicaid Management Information Systems, noting major progress in the private sector which can result in cost savings over time for clients. At the same time, states find themselves in need of upgrades. A wave of upgrades is likely to continue over the next ten years as successive states’ contracts expire and their systems become obsolete.
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Health Information Technology: A Few Years of Magical Thinking?
Source: Health Affairs
Date: 08/19/2008
Health care information technology solutions are usually touted as a cure-all for the ills of inefficiency in our health care system, if not the cure for the health care crisis on the whole: everything will be fixed as soon as hospitals are all on EHRs and electronic prescriptions. Not the case, says a paper published in Health Affairs. Information technology is just a facet of a larger transformation needed in American health care.
The paper argues against “magical thinking” with regards to health care information technology—such as the belief that technology can fix all problems in the system on its own. Rather, argue the writers, integrated policy work and incentives are necessary for a healthier system designed to go hand in hand with the new technology.
The article claims that the focus on standards in IT in particular is misplaced and premature. The authors argue that standards won’t be able to be adopted until there is a real reason for them. That is to say, standards will not be adopted until the technology is more widely adopted, necessitating standards. Attempts to “make” standards, then, are misguided and bound for complications, since standards arise by popular consensus generally.
The authors argue, instead, that more open standards should be allowed initially, allowing the health care IT market to sort itself out. Doctors should be motivated to adopt IT, and from there, sharing will result, which will eventually necessitate standards, which will likely arise naturally. The authors posit that the best investment is getting the doctors online and digitized in the first place, and the rest will work itself out over time.
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Online Doctors Make House Calls Again
Source: Connecticut Post
Date: 08/22/2008
More doctors need to go online, embrace technology, and give patients new ways to contact and connect with the healthcare system. These are the recommendations of a report released by the National Center for Policy Analysis.
The report finds some doctors are answering questions via email, but also treating patients over the Internet. An example of such practice is Tela-Doc, based out of Texas, which hires licensed doctors to provide medical evaluations and diagnoses after reviewing a patient’s medical history and conferring through telephone consults. While critics say this is no substitute for traditional health care, proponents say it is only meant to be a supplement to actual physician visits, a supplement which can save patients money.
The study’s author says that doctors are slow to adopt new technological solutions. Also, questions remain regarding the jurisdiction of doctors. Is a doctor licensed in Rhode Island allowed to tele-diagnose in Kansas? What does one charge for a phone call check-up? Insurance companies are unpredictable in their willingness to cover such services, though proponents still see potential in the practice, envisioning tele-evaluation of the progression of healing, electronic reviews of X-rays and MRIs, and specialist consultations via video-conferencing.
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Physician Practice Management
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Maximize Your Collections with Better Billing
Source: Medical Economics
Date: 08/15/2008
Billing at times seems like the smallest of concerns, but special attention to proper coding can result in a vastly improved bottom line. In the August issue of Medical Economics, an administrator from the ob-gyn department of Albert Einstein Medical Center explains how proper coding, IT and a department retreat helped pull them from two million dollars in the red back to profitability.
The department started out sloppy: paper charge tickets often weren’t properly filled. Billing codes weren’t fully transcribed; diagnostic codes lacked specificity. This caused the department to miss filing dates and lose money.
The solution began with a day-long billing retreat. Departmental staff was drilled again and again on the importance of proper and complete billing and coding, with everyone being made aware of their role in the process. Next, an IT solution came in the form of handheld computers for doctors to use in diagnosis, billing, and prescribing. With the addition of Electronic Health Records, the department’s IT component was in place. The computers held all billing codes, with easy access to the most common ones. As a result, the computers were able to complete codes automatically for electronic filing, reducing paperwork, man-hours spent on administrative tasks, and the risk of misfiles.
Despite initial fears of decreased productivity, the handheld system resulted in an increase of 30% in gross charges over the first year. Days in accounts receivable fell from an average of 74 in 2003 to 39 in 2007, with the denial rate shrinking from 5% to 3%. There are plans to introduce the system on a wider scale in the hospital, which administrators believe will result in similar savings for the whole operation.
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Making Practices Perfect
Source: Washington Post
Date: 08/26/2008
In the midst of a national dialog regarding health care, many buzzwords are tossed about. One avenue arising is the “micro-practice,” a low overhead, high tech office that cuts much 20th Century dead weight, resulting in what some doctors say is a more friendly and personal practice. An article in the Washington Post investigates.
The article centers on two small Washington clinics beset by patient loads and increasing staff and administrative demands. Frustrated with setbacks, the director enrolled in an Institute for Healthcare Improvement program teaching business techniques. As a result, her clinics now operate on computerized medical records, with reductions in waiting times. They also accept services from volunteering specialists, expanding the range of offerings they can provide to clients.
This micro-practice, in large part, means for its director a greater degree of freedom and personal interaction with patients. No longer stuck with the traditional practice set-up, patients don’t crowd in a waiting room to receive service: they enter and ring a bell and are greeted by the director or the physician who will be working with them. The head physician even personally meets with patients outside of the office to perform minor check-ups, also remaining on call for them for extended hours so that they need not go to the emergency room unless absolutely necessary. The director claims that the micro-practice results in a more satisfied clientele and physicians feeling like they’re accomplishing something.
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Patient Relations: Who’ll Stop the Rain?
Source: Physicians Practice
Date: 07/01/2008
In any practice, difficult patients are inevitable. They typically demand more attention from doctors and their staff and require more time and energy to be spent responding to their concerns. Often, doctors’ responses can end up exacerbating the problem due to poor communication. Difficult patients are not going away, as an associate professor at the University of Virginia points out; so it is in the doctor’s best interest to learn how to effectively handle them. Suggestions include:
-Asking the patient to describe their worst health concerns. Often a simple reassurance from the physician that their cold will not become lung cancer will put them at ease.
-Focusing on the patient’s verbal and nonverbal cues to evaluate their comfort level, and adjust your response as appropriate.
-Maintaining eye contact. This conveys a sense of sincerity in wanting to communicate openly.
-Legitimizing the patient’s feelings and letting them vent briefly if angry.
-Bringing in another doctor to support you if the patient will not listen.
-Explaining the reasons behind recommended treatments and the consequences if your advice is not followed. Use visual aids to help the patient to understand.
-Asking your patient to repeat your instructions, and write them down if necessary.
-If a patient presents himself with a long list of complaints with no physical symptoms, first ensure that there is no medical cause. If the patient persists, instead of ordering an MRI to placate him, recommend more limited tests such as an X-ray.
-Do not hesitate to ‘fire’ a patient if he or she becomes abusive.
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Breaking the Typical Practice Model
Source: Southern California Physician
Date: 08/01/2008
A head and neck surgeon in California decided once to go off of the insurer contract system. The payers were too stubborn in giving full payment, and the administrative facet was a nightmare. The surgeon thereafter watched business at his practice trickle and then slow to a halt before he was forced to return to the system he’d abandoned. Even done by the book, switching from the typical practice model can be hit or miss. An article in Southern California Physician examines some Do’s and Don’ts in this regard.
The article acknowledges the tumultuous period American health care is currently going through. The cost of service is going up while patients are less able to pay and insurers are paying less and less. Added to that, some powerful insurers won’t even negotiate with an entity smaller than a hospital, leaving private practices in the lurch.
Some doctors make the switch away from the typical practice model because of the aforementioned market factors. Some switch to try to outperform their lowering reimbursement rates. For others, it is a combination of influences such as the difficulty of work, the desire to practice by different means, or the desire to spend more time with patients than is permitted given the strict contractual standards common among payers.
Payers are trying to stem this trend by putting up obstacles to contract cancellation, trying to divert patients elsewhere. They inform patients that they are no longer covered for certain doctors and generally attempt to divert patient flow. Through perseverance, though, a number of doctors have survived the transition.
If considering the transition, doctors must maintain sufficient communication with patients. When switching, inform your patient base of your plans and your payment proposals and reasoning well in advance. Maintain contact and show clear contrast to the payer prices.
Total abandonment of the contract system might not be necessary if one can just remove a few offending payers. View the top 20 CPT codes for your practice and the subsequent billing numbers for them. Then compare the payer rates among them to see which payers are most advantageous to drop. Even if you don’t pull out of the system entirely, you may be able to positively affect your bottom line by making the best of the ones you’re working with at the moment.
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Start It Up: Operations—Everything in Its Place
Source: Physicians Practice
Date: 08/01/2008
When just starting out, the feeling one doesn’t know what one is doing can be overwhelming. It’s likely, though, that neophytes are treating the practice as though it is more complex than it has to be. An article in Physicians Practice examines the core issues that one has to get right for success in new practice.
The article points out that getting financial affairs right means a new practice is most of the way to success and recommends the following:
-Use electronic filing options if possible: File everything as soon as is possible. To keep cash and funds flowing smoothly through your practice, putting everything online is the best option.
-Maintain a set of customizable form letters: This makes appeals of denials easier and quicker to file.
-Review EOBs every couple of weeks to make sure you’re being paid the rates promised to you.
-Accept electronic payments: Getting automatic payment posts dramatically increases your operational efficiency. Credit and debit payments are strongly encouraged.
-Closely track performance: Keep an eye on key indicators like days in accounts receivable, net collections percentage, etc., and follow closely whatever else is important to you in your practice.
Pay attention to payers, the article also recommends. Payer contracts directly affect your accounts receivable records for years; so special attention to them is well warranted. Figure out whether you can afford to drop a payer as a means of possible leverage in negotiations. Key features in selecting payers to work with include timely filing windows, equal appeals periods, and ease of contract termination.
Also ensure that your practice has a network of solid support, including local physicians, professional groups, and even contacts from your alma mater. These tips, in conjunction with regular communication with your staff, should result in increased efficiencies and overall better administrative operations for your new practice.
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