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The economic downturn that grabbed the public’s attention
starting with Wall Street’s bailout last fall shows no signs of abating any time
soon. The fact is, the U.S. is experiencing a deep recession that has yet to
bottom out, according to most economists. It remains to be seen how soon we’ll
see any significant turnaround.
How has the faltering economy affected health care delivery among U.S. hospitals?
This month’s Special Report addresses this question by focusing on how a number
of hospitals and healthcare systems across the country have confronted the
reality of fewer patients, diminished revenue, and unanticipated staff cuts. To
balance the analysis, our research staff also points out some positive,
innovative measures hospitals are taking to address their fiscal challenges
head-on while maintaining quality patient care. Read the report….
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By J&C Research Associates
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The
Economy and the Future of Health Care
Watching the evening news, the latest reports on the economy are pretty bleak. Massive layoffs, homeowner
foreclosures, business closings, the downward trend in the stock market,
disputes over how federal bailout funds should be allocated, proposals for a
massive economic stimulus – all these stories create a mixture of confusion,
foreboding, and faint hope in the minds of many TV viewers.
Readers of this publication are likely to
wonder: “How has the economic
downturn affected the health care industry?”
And “How might the floundering economy affect my job?”
For years, it was thought that the health care
profession was virtually immune to major fluctuations in the
U.S.
economy. After all, no matter how
the economy vacillates, people still get sick and need medical care. So we
thought. The reality we’re experiencing defies conventional wisdom, however, as
our special report discusses.
“Health Care and the Economy—Can Hospitals
Afford a Recession?” points out the direct impact the current economic downturn
has had on hospitals across the country.
Not a gloom-and-doom assessment, the report discusses cost-cutting
measures, revamped construction plans, and other innovative approaches for
fiscal belt-tightening proposed by hospital executives and administrators.
Looking at the economy and health care more
broadly, this month’s Jackson &
Coker Industry Report includes
information gathered by Deloitte’s worldwide health care consultants. By special permission, we’ve provided
a link to the portion of Deloitte’s website that discusses “forces that are
shaping the global health economy.”
A number of feature articles in this issue
provide additional perspective on how the economy has impacted certain physician
specialties. It remains to be seen how the health care
landscape will look months or years from now.
For the present, any glimmer of hope is much appreciated.
Cordially,
Calvin Bruce
Managing Editor
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The forces and factors that influence the future
of health care delivery in the United States must be understood in the broader
context of what is shaping the global health economy, according to Deloitte’s
Health Sciences practice.
To address these complex issues, Deloitte LLP’s
Health Sciences & Government Practice and the Institute for the Future’s (IFTF)
Health Horizon’s Project have produced an online visual guide entitled
Compass 2.0 map. Designed for interactive usage, the
guide surveys the global health economy terrain by spotlighting major factors
referred to as “Drivers, Impact Zones, Trends, Signals, Hurdles, Landmarks and
Artifacts.”
We invite readers to navigate throughout the
entire Compass 2.0 map to better
comprehend the complexity of concerns that must be addressed to adequately
understand where the global health economy is headed over the next decade.
The information provided by the Deloitte study
benefits health care providers, hospital executives, payors, IT directors,
biomedical scientists, health care policy makers, and other members of the
medical community.
Deloitte Study
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Physicians Enjoy a Year-End Rush
Source: startribune.com
Date: 12/29/2008
At the end of 2008, a new phenomenon in health care was brought on by the increase in health insurance plans with deductibles. These health insurance plans create incentives for patients to hold off on getting care because they are paying out-of-pocket. However, later in the year, some patients have paid enough to reach their deductible and have their insurance kick-in, thereby creating an incentive to wait for treatment until it is covered.
The consequent jump in health care spending at the year’s end means that hospitals across the nation are getting hit with record numbers of colonoscopies, hysterectomies, hernia surgeries, and knee replacements. Medical groups are grateful for the increase in business, which may help to offset some of the impact of the weak economy on the health care industry. To cope with increased patient demands at the end of the year, many doctors are working extra hours and delaying vacations.
High-deductible plans with health savings accounts, introduced in 2004, are becoming increasingly popular. At the same time, deductibles for traditional preferred provider plans have also increased, with an average $1,000 deductible. Despite the increase in spending on treatment at the year’s end, these deductibles have helped to slow the rate of health care spending in general.
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Medicare 2009 Payment Rules Yield Winners and Losers
Source: Urology Times
Date: 12/01/2008
The 2009 Medicare Physician Fee Schedule final rule, as published in the Final Register, contains some significant payment changes relative to the previous year. The conversion factor for 2009 is set to $36.0666, in contrast to the 2008 conversion factor of $38.0870. This drop in the conversion factor reflects the Medicare Improvements for Patients and Providers Act passed in July 2008 which increased Medicare physician payments by 1.1% and eliminated a 10.6% cut in payments for 2008. The Medicare Improvement Act also eliminated a 5.4% projected cut for 2009.
The payments for the main E&M codes used by urologists, consults and patients are set to increase by 1.5% overall. Ultimately, however, the payment for certain procedures will decrease dramatically. For example, payment for office procedure 52214 (cystourethroscopy, with fulguration of trigone, bladder neck, prostatic fossa, urethra or periurethral glands) will decrease by 52%. Furthermore, payment for microwave of the prostate and urodynamics will drop by 17.4% and 7%, respectively. Payment for cystoscopy performed in the office, in contrast, will experience a slight increase. In general, those services whose relative weight “for the practice expense is significantly higher than its work value will be impacted negatively” by the 2009 Fee Schedule.
CMS has also created four new G codes for prostate saturation biopsies under the Health Care Procedure Coding System, with the differences in the codes based on the number of specimens, and a new series of codes for follow-up inpatient telehealth consultation has been added.
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A Look at Where Kidney Care May Go in 2009
Source: NephrOnline.com
Date: 01/05/2009
2008 proved to be an especially important year in kidney medicine with Congress passing the Medicare Improvements for Patients and Providers Act, which, among other things, allowed for the establishment of bundled payments for composite rate reimbursements provided to dialysis facilities. Looking forward, the changing health care landscape looks to have a sizeable impact on renal care.
MIPPA’s passage addressed some concerns among health care practitioners, such as physician payment rates, but it did so on a temporary basis. The bill was only written to endure for 18 months before its alterations to payment structures expire. One side effect of MIPPA’s passage, then, will be enormous pressure on Congress and the executive branch to address reductions in reimbursement that could cripple access to medical care and the physician workforce.
Nephrologists will find themselves having to deal with Conditions for Coverage changes that affect the responsibilities of dialysis facility medical directors and possible changes in the Medicare fee schedule. The Conditions of Coverage, which outline major areas of responsibility for medical directors, are specific to an extent previously unseen, taking into account patient assessment, quality assessment and performance improvement, staff education, staff training, and infection control, among other factors.
Now, dialysis facility medical directors will be responsible for much more in the patient care process chain. Added to this, the Medicare fee schedule sees increases in payments to nephrology as a specialty of approximately two percent for 2009. However, reimbursement for many nephrologists’ interventional services experienced substantial reductions in reimbursement, and CMS indicates it will seek further review of recently established values for outpatient dialysis codes.
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Nearly Half of Physicians Say They Plan to Cut Back or Quit
Source: Geriatrics
Date: 11/18/2008
The results of a survey released by The Physicians’ Foundation indicate that Americans may suffer from decreased access to physician care in the near future. According to the survey, which was mailed to virtually every physician engaged in active medical practice across the U.S. and received a total of 11,950 responses, 78% of physicians believe that there exists a domestic shortage of primary care doctors. Yet, 49% of the respondents indicated that “over the next three years they plan to reduce the number of patients they see or stop practicing entirely.”
The most commonly reported reasons behind this frustration amongst physicians pertain to greater time spent dealing with non-clinical paperwork, the difficulties involved in receiving reimbursement for services rendered, and taxing government regulations. Ultimately, physicians expressed the fact that these obstacles prevent them from enjoying the most rewarding facet of their job: developing patient relationships. Specifically, 63% of doctors said “non-clinical paperwork has caused them to spend less time with their patients,” while 94% of the respondents noted that the “time they devote to non-clinical paperwork in the last three years has increased.”
Some other notable survey results include the following: only 17% of physicians rated the financial position of their practices as “healthy and profitable,” 76% of physicians said they are either operating at “full capacity” or feel “overextended and overworked,” and 42% of physicians said the professional morale of their colleagues is either “poor” or “very low.” Furthermore, “declining reimbursement” was rated by physicians as the highest impediment to patient care delivery in their practices. Ultimately, 60% of doctors noted that they would not recommend medicine as a career to young people.
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Data-Driven Health Care Becoming All the Rage
Source: LoHud.com – New York’s Lower Hudson Valley
Date: 01/04/2009
Belief in the potential of electronic medical record-keeping (EMR) technologies and data-driven medicine to help revitalize health care is reflected in President Obama’s economic recovery plan.
Pledging to “make sure that every doctor’s office and hospital in this country is using cutting-edge technology and electronic medical records so that we can…prevent medical mistakes and help save billions of dollars each year,” Obama has pledged to spend $50 billion over five years to increase the adoption of electronic health records.
While data-based medicine and electronic records are not a new concept, adoption in the U.S. is slow, with just under 39 percent of U.S. doctors using EMR technologies, compared to 98 percent of doctors in the Netherlands and 89 percent of doctors in Great Britain.
This percentage is about to increase, however, in the New York area with the implementation of a $60 million Health Department project to build a database of detailed patient information and the New York State Health Commissioner’s plan to unveil an online health data collection tool that allows New Yorkers to check the prevalence of 12 preventable conditions.
Recent initiatives such as these complement New York Governor David Paterson’s $100 million investment in health care to strengthen the state’s primary care system, which should work to lower hospital usage and costs and eliminate disparities in health care. Data-driven health care supports this investment by allowing localities, hospitals, and other care providers to collaborate on earlier screening and treatment plans.
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Nobel Winner Sees End to AIDS Spread Within Years
Source: Reuters
Date: 12/06/2008
The transmission of AIDS could be eliminated within years, according to Luc Montagnier, Director of the World Foundation for AIDS Research and Prevention and the 2008 co-winner of the Nobel Prize for medicine. Montagnier, speaking at a press conference in Stockholm during “Nobel Week,” noted that he hoped to witness the eradication of the HIV infection during his lifetime while recognizing that the AIDS epidemic itself could not be eliminated in that time. Montagnier and Francoise Barre-Sinoussi of the Institut Pasteur were awarded the Nobel Prize for medicine for their discovery of the HIV virus in the early 1980s.
While there is currently no cure for AIDS, researchers are in the process of developing a therapeutic vaccine which would either prevent infection or control the virus so that “patients are less likely to transmit it.” According to Montagnier, he and his colleagues have been working on developing such a therapeutic vaccine for over a decade and are hopeful that their efforts will come to fruition within four to five years.
Barre-Sinoussi expressed her fear that the global financial crisis could lead to some countries decreasing their commitment to fighting AIDS, tuberculosis, malaria and other diseases. According to her, it is critical that Nobel winners use their influence and resources where possible to further the cause.
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More Injured Workers Using Physician Networks
Source: Sacramento Business Journal
Date: 12/18/2008
In California, a program designed to improve the efficiency of care and coordination of benefits in worker’s compensation claims is gaining popularity among injured workers, according to a report released by the California Worker’s Compensation Institute this week. The program, which became effective January 1, 2005, allows insurers and self-insured employers to create medical provider networks, or MPNs, which consist of a state-approved mix of doctors specializing in a variety of common work-related injuries and illness, as well as general medicine. Employers may then require injured workers to receive care from a physician in the MPN for the entire duration of the claim. Prior to the 2005 regulation, California employers could oversee only the first month of treatment.
The research, which studied medical visit data from almost 1.1 million worker’s comp claims in the five years between 2002 and 2007, reveals that the first year of implementation of the MPN program saw a nearly 100 percent increase in the use of doctor networks by worker’s comp patients, with popularity continuing to increase steadily. The rate of network use rose from about one-third in 2002 to 60 percent in 2005 and 63 percent in 2006.
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Do Patients Trust Doctors Too Much?
Source: The New York Times
Date: 12/18/2008
When it comes to surgery, patients generally place an enormous degree of blind trust in their physicians, a recent New York Times article reports. As the newest additions to Angie’s List, the consumer protection website that began as a venue for customers to rate area home improvement contractors, doctors are “graded” by patients according to a generic report card that takes into account price, quality, responsiveness, punctuality, and professionalism. However, reviewers tend to grade physicians based mainly on attentiveness and bedside manner rather than technical expertise.
This trend, while perhaps unsurprising, is the more troubling after considering that Angie’s List users—and presumably other patients as well—are much more likely to take skill into account when judging a roofer or other contractor. This anecdotal evidence is supported by a large survey conducted this year by the American College of Surgeons, which among other things found that Americans spend more time on average researching a new car than a new surgeon. In fact, over a third of those who had had an operation in the last five years failed to explore the credentials and training of their surgeon at all.
Executive director of the College, Thomas Russell, was so alarmed by the study’s findings that he wrote a book entitled I Need an Operation…Now What? to help patients make more informed decisions. Regarding patients’ high degree of trust in their physicians, Dr. Russell said, “If we are truly going to reform the health care system in the U.S, everybody has to participate actively and must educate themselves. That means doctors, nurses, other health care professionals, lawyers, pharmaceutical companies, and insurance companies. But most of all, it means the patient.”
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Florida Doctors’ Shortage Trend Only to Worsen, Report Reveals
Source: Naples Daily News
Date: 12/16/2008
At a time when economic conditions ensure that reliance on public health care programs is certain to increase, Florida is poised to experience a deepening doctor deficit, according to a new state sponsored survey. Thirteen percent of physicians respond that they plan to either significantly reduce or entirely leave their current practices in the next five years (although whether they plan to join another practice is unclear). Additionally, data show that 11 percent of doctors who take emergency room calls have already decreased the hours they spend there over the last two years.
Experts in the state say that the survey yielded no surprises but that it does help to highlight the need for more doctors—a need which anecdotal evidence has borne out for years in Florida and beyond. “Florida follows similar national trends that primary care physicians and young residents are going into specialties where they don’t want emergency room calls or extended hours,” says Program Director with the Florida health department, Jessica Swanson, who worked on the study.
Other alarming findings include that Florida’s doctors are aging (only 36% are between 25 and 45 years old); that 40% of OB/GYNs have stopped delivering babies, while another 18% are considering cutting that portion of their practice in the next two years; and that only 31%, or 6,758 doctors, are still taking emergency room calls. The state Surgeon General has created a task force to address the shortage, but with a 2.3 billion budget shortfall and the grim state of the federal Medicare program (which funds residency slots), aggressively recruiting the doctors Florida needs will prove difficult.
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How to Conduct Clear, Effective Staff Evaluations
Source: Urology Times
Date: 12/01/2008
A performance evaluation is a critical tool through which practice managers and physicians can gain a greater understanding of their employees while communicating with them regarding performance and expectations. When executed properly, these evaluations serve to motivate employees to “put their best foot forward” and can, ultimately, lead to enhanced overall productivity.
In establishing a performance evaluation system, one must aim to provide the following: an objective measurement of an employee’s contribution to the workforce, an opportunity to discuss performance issues, and a suggested path through which the employee may achieve or develop the desired work habits, attitude and technical skills. Ultimately, the most important goal of a performance evaluation system is to help the employee identify ways in which he or she can enhance their contribution. In light of this, one must not simply focus on the employee’s strengths and “gloss over” his or her weaknesses and deficiencies. Furthermore, some employees may require coaching or extra training and clarification in order to achieve their desired performance levels. Practice managers and physicians must be prepared to identify these instances and accommodate accordingly.
It is critical to support performance reviews with standardized job descriptions, position-specific performance standards, salary guidelines per position, and a rating mechanism—these tools contribute to the efficient and effective nature of performance evaluations. Evaluations must be timely, consistent, and thoroughly executed. Failing to meet set deadlines may lead employees to feel devalued and neglected.
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Alberta Bound: Why South African Doctors are Coming to Canada
Source: Financial Post
Date: 12/11/2008
South Africa has one of the world’s highest violent crime rates—meaning doctors are constantly dealing with the victims of gunshot wounds, stabbings, and rape. Combine this with poor governance and an enormous gap between the rich and the poor and many South African physicians have started to leave the country to work in other countries around the world.
The South African Medical Association acknowledges that doctors are leaving in droves for countries like Canada, Australia, and the United Kingdom. Half of the physicians trained in the country during the past decade are no longer registered to practice there. Dr. Kgosi Letlape, chairman of the association, says that their “ability to retain doctors is nonexistent.”
South Africa’s loss, however, has turned into Canada’s gain. Small Canadian towns and rural communities are suffering a shortage of domestic physicians; so they’ve begun recruiting South Africa’s skilled, English-speaking doctors and sending them to areas where Canadian medical grads are reluctant to work.
Nearly 2,100 South African-trained physicians now practice medicine in Canada, with about a quarter of them in Alberta. The number of doctors moving to Canada from South Africa nearly doubled since the country’s first democratic elections in 1994.
Conditions in South Africa aren’t their only motive, however. Many are enticed by higher and more reliable salaries and by incentive packages worth up to $50,000. The Aspen Health Region, for example, offers a $10,000 relocation allowance and a $10,000 signing bonus. A provincial program adds another $15,000 to $20,000 if the physician remains in the community for more than nine months.
The competition for South African doctors has even led to bidding wars between some communities—perks like cars, homes, and interest-free loans have sweetened an already appealing offer.
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Employment & Compensation
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UMC Physicians to be Asked for Contract Concessions
Source: Review Journal.com
Date: 01/05/2009
The Clark County Commission has recently directed the University Medical Center of Southern Nevada, which now has more than $60 million in debt even before factoring in upcoming reductions in the Medicaid reimbursement rates set by the state’s Department of Health and Human Services, to ask service providers to follow the Commission’s example and make financial concessions in their contract payments.
UMC currently spends $37 million for about 20 professional service contracts and is looking into decreasing professional provider contract rates to help lower its growing debt. This measure is in addition to closures to the oncology unit and program cut-backs. In the attempt to decrease the amount of money paid to service providers, UMC administrators are planning on contracting provides whose contracts are up for renegotiation and then contacting those providers whose contracts have already been negotiated.
Administrators believe that there is a cost-cutting opportunity, as many physicians are loyal to the hospital and understand its financial problems. However, the executive director of the Nevada State Medical Association says that while it is understandable for UMC to want to review this option, some practices may not have the financial flexibility to take pay cuts. Yet even with the weak economy, some physician groups have already restructured their contracts to help UMC save money. Las Vegas Pediatric Critical Care Associates, in fact, has not increased its contract rate with UMC since 1998, apart from cost-of-living adjustments.
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HHS’ Inspector General Issues Opinion on Part-Time Workers
Source: Modern Healthcare
Date: 12/16/2008
The HHS has released an advisory opinion requested by an unidentified physician group that clarifies the legal status of part-time physicians. Under federal anti-kickback laws, it was unclear whether part-time physicians with their own practices could legally work with physician groups part-time and receive payment for services covered by Medicare, Medicaid, or other federal health programs.
The opinion validates the legal status of part-time bona fide employees as effectively the same as full-time employees under the anti-kickback statute’s employment exception and safe harbor clause.
Other recent opinions had suggested that similar arrangements were a grey area, with potential for fraud and abuse, but enough safeguards in place that the HHS’ Inspector General’s office declined to seek sanctions. This new opinion should help to clear up their status.
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Screening Malpractice Suits is Lowering Costs
Source: Concord Monitor
Date: 12/17/2008
A new malpractice law in New Hampshire has established panels to screen cases before trial in hopes of cutting down on the costs and frustration of medical malpractice trials. The idea is to leave out the “theatrics we so often see in front of a lay jury,” as one physician put it, and allow for a more deliberative process. The panels are composed of a judge, lawyer, and physician expert, and a unanimous decision by the panel is admissible in court. Unanimous decisions are far more likely to be dropped or settled.
The one-day panels allow the panel members to study the facts of the case, read expert testimony, and then hold hearings where they can question both sides and experts.
Of 76 decisions made by panels since the law was adopted, 63 were unanimous, and only four of these subsequently went on to trial. This suggests that screening panels do, indeed, dramatically reduce the need for expensive jury trials. As has been the case, 60 percent of malpractice premium dollars go to lawyers and expert witnesses, with only 40 percent awarded to injured patients and families.
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Utilizing the Power of the Web: Medical Resources for Attorneys
Source: Attorney’s Medical Services
Date: 12/01/2008
The Internet provides a wealth of free information on medical and related topics, but one must be well-versed in the art of Internet searching to quickly and consistently find literature on a given subject.
The first step in embarking upon any Internet search is to define the search as clearly as possible. One must decide what type of information will be searched for and identify the topic’s main concepts as well as applicable synonyms, alternate spellings and variant word forms. A basic understanding of medical terminology is critical in defining one’s Internet search. It may be helpful to secure access to a medical dictionary and drug guidebook to minimize the possibility of misspelling search terms.
Next, the Internet search must be executed. Most major medical literature search sites are equipped with tutorials that help you become familiar with the way in which the search tools function. Ultimately, time invested in learning the specifics of a particular search site will pay off considerably with your ability to perform quick and effective searches in the future. As you become comfortable with certain search sites, try to avoid excessively narrowing your sources. It is best to use a wide variety of search sites in an effort to broaden your information pool and develop your familiarity with the strengths and weaknesses of the sites available to you.
The Internet is in a state of constant change. You may find that recycling past search terms or phrases may not lead you to the same sources of information. Ultimately, taking a trip to the nearest medical library may be your best option if your Internet search efforts come up fruitless.
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Transplant Surgeon Acquitted in Case Involving Potential Organ Donor’s Death
Source: Los Angeles Times
Date: 12/19/2008
The highly anticipated verdict of a case which has highlighted the sometimes fuzzy nature of ethical lines in medicine arrived Thursday, December 18 when jurors found transplant surgeon Hootan Roozrokh not guilty of dependent adult abuse. The two-month trial explored the circumstances surrounding the death of Ruben Navarro, a 25-year old man suffering from a painful neurological disease whose brain was severely damaged but still functioning minimally. Navarro’s mother had granted permission for her son’s organs to be harvested in a procedure known as donation after cardiac death, but prosecutors argued that Roozrokh wrongly administered mega doses of morphine and Ativan so that the patient’s heart would stop within the critical 30 minute window of time during which organs are still viable transplants. Because Navarro ultimately lived for eight hours after being removed from life support, no organs were harvested.
While the District Attorney’s office claimed the surgeon “prescribed drugs with abandon,” Roozrokh testified that he acted ethically by trying to ease the pain and fear that the suffering man may have been silently experiencing. Treatment of a patient by a member of the transplant team is highly unusual, and many hospitals prohibit the surgeons from even being in the room until the patient is declared dead. However, the procedure in question had never been performed at Sierra Vista Regional Medical Center in San Luis Obispo, and prosecutors and Roozrokh alike painted a picture of a chaotic operating room in which roles and procedures were unclear.
Some experts have feared that this highly publicized case would discourage potential donors, but a spokesman for the nonprofit OneLegacy, an organ donation organization in the Los Angeles area, says donations have not decreased because people understand that the Navarro case is very much out of the ordinary.
Roozrokh still faces a hearing before the Medical Board of California.
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Primary Care Doctors Struggling to Survive
Source: LA Times
Date: 12/15/2008
The recent financial crisis has hit primary care doctors particularly hard, with rising overheads and low earnings driving many doctors, particularly those with small practices, out of business. According to the New England Journal of Medicine, older physicians are being driven into retirement, and new medical school graduates are being drawn into high-paying medical specialties.
Central to this problem is the business model of the one- or two-physician general practice. Small margins have fallen into the red as patients default on bills and overall operating costs rise. While this model gives doctors a great deal of autonomy and encourages doctor-patient bonds, their size leaves them vulnerable since they have no economy of scale or leverage with insurers or suppliers. Physician revenues across the country have fallen as patients fail to pay bills or simply skip appointments to save money. As Jeffry Luther, president of the California Association of Family Physicians, said, many people are “putting off physicals and mammograms and blood tests because they just don’t have the cash.”
Some primary care physicians have increased their income by offering luxury treatments like Botox injections and cosmetic procedures, but many are unable to afford the training or serve poor and working-class patients who can’t afford these treatments.
Multi-office practices may tempt many doctors to close down their own offices in favor of a stable income, bonuses, vacation time, insurance, pension plans, and paid training.
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Changes in Doctor-Patient Visits Could Save Primary Care Medicine
Source: PressofAtlanticCity.com
Date: 01/06/2009
Two years ago, the American College of Physicians predicted the impending collapse of primary care medicine in this country, faulting its financing and delivery system as critically flawed. A recent Physicians Foundation survey found low morale, overextension, overwork, and insufficient pay among the majority of responding primary care physicians. Taking into account the necessity of primary care, even in the face of these dismal numbers, one doctor proposes a model to save the field.
Writing in the New England Journal of Medicine, Dr. Thomas Bodenheimer proposes a reorganization of primary care into a team-based endeavor. His proposal centers on primary care physicians stratifying patient needs and organizing services accordingly. Under Bodenheimer’s system, preventive care patients would be treated by non-physician “panel managers,” with patients gaining increasing access to physicians’ clinical time depending on the severity of their affliction. Doctors in this sense would function as team leaders with at most ten patient visits per day, spending the rest of their time being involved in consulting with team members, handling physician-level telephone and electronic encounters and ordering medication changes, which would then be carried out by associated staff such as health coaches.
Adoption of this model would require a revamp of the payer system, which generally pays only for the cost of face-to-face encounters between physician and patient. A pilot program of just such a payer system reinvention has been undertaken in Atlantic City, NJ. Whether such a system would be the answer to American primary care needs and healthcare problems at large remains to be seen, but the pilot program’s designer believes it will lead to increased primary care physician enrollments as well as cost savings, better outcomes, and greater efficiencies overall.
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Psychiatrists Revise the Book of Human Troubles
Source: The New York Times
Date: 12/17/2008
The American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-V) has been a powerful and highly debated medical and social tool since its inception in 1952. Currently, panels of psychiatrists are in the process of debating exactly what will and will not be categorized as a mental problem in the fifth edition of the manual, to be published in approximately three years.
The results of the symptoms and mental problems included in the DSM-V will have significant long-term consequences for insurance reimbursement, research, and individuals’ psychological identity. The most recent edition of the manual, published in 2000, includes nearly three times the number of disorders published in the first edition.
Some of the most crucial debates over the new manual will cover topics like gender identity, illness involving children, and addictions such as shopping and eating. Often, debates over what to include in the DSM-V are as much social debates as medical debates.
Due to the important medical and social implications of the manual, scientists working on the new manual have agreed to policies protecting medical diagnoses from industry influence. The new policies are partially in response to questioning of a surge in diagnoses of bipolar disorder by psychiatrists on pharmaceutical payrolls.
Regardless of authors’ decisions regarding which symptoms and disorders should be included, the publishers of the DSM-V may be fairly certain of its success, as the two previous editions sold more than 830,000 copies each.
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Washington Worst in Nation for Emergency Healthcare
Source: Issaquah Press
Date: 01/05/2009
The state of Washington gets a flunking grade when it comes to its residents’ access to emergency health care, and the state’s grade for its medical liability environment is just barely better—this according to the American College of Emergency Physicians’ recently released “National Report Card on the State of Emergency Medicine.”
The report, which also looks at criteria including access to care, quality of care, and public health, graded Washington’s emergency healthcare system an ‘F,” the worst in the nation. The state’s medical liability environment grade, the study’s authors say, stems from the lack of a cap on non-economic malpractice damages and a lack of a requirement that expert witnesses work in the same specialty as the defendant.
The failing emergency care system in Washington stems from a number of factors, including delays in care and a shortage of beds. Administrators statewide place the blame for the problems on the near constant full-capacity status of Washington hospitals, with regional hospitals operating at around 98 percent capacity on a daily basis.
The problem is not easily solved. Building more emergency rooms and hospitals is not an answer in and of itself, as those facilities would find themselves understaffed in the face of the state and nationwide doctor and nurse shortage, which is forecast to only get worse in the coming years as more health care professionals retire.
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Ruling Removes Billing Headache from Emergency Room Visits
Source: Los Angeles Times
Date: 01/09/2009
In a ruling initiated by a dispute between emergency physicians and a Southern Californian physician organization that functions as an HMO for emergency care patients, the California Supreme Court decided that patients no longer have to worry about getting billed for emergency treatment charges that their HMOs fail to pay.
The decision is based on disputes concerning the practice of “balance billing,” which occurs when a patient is treated for an emergency at a hospital that does not have a fee contract with the patient’s HMO. During these situations, HMOs say physicians and hospitals often submit inflated charges, while hospitals and physicians argue that without minimum fee requirements, they are underpaid by HMOs.
Health maintenance organizations and patient advocates, on the other hand, endorsed the decision as an important protection against patient over-payment. Both Governor Arnold Schwarzenegger and the chief executive of the California Association of Health Plans support the ruling as an effort that should help contain healthcare costs and protect consumers. Physicians are concerned, however, that the ban on patient billing removes their ability to attain fair payment from big HMOs and that the loss in income resulting from the ruling could strain already strapped hospital emergency rooms and discourage specialists from taking emergency cases.
But even considering these concerns, insurer Kaiser Permanente is pleased with the ruling, especially in light of the fact that the decision may affect a case between the insurer and Prime Healthcare, a hospital chain that sent thousands of bills to Kaiser members for emergency care.
As the president of Kaiser’s Southern California region stated, “The decision provides much needed protection for California patients, taking them out of the middle of billing disputes between providers and health plans.”
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University-Based Research Facility Brings Together Six Cosmetic Specialties
Source: Cosmetic Surgery Times
Date: 11/15/2008
In an effort to cut through research “red tape” and bring together six cosmetic specialties into a single collaborative environment, the University of Miami Miller School of Medicine has launched the Cosmetic Medicine and Research Institute (CMRI). CMRI, the most comprehensive of any established university-based cosmetic research institute in the U.S., is unique in its combination of cosmetic dermatology, facial plastic surgery, oculoplastic surgery, plastic surgery, and nutrition. Maxillofacial surgery will soon be added as the Institute’s sixth specialty.
The benefit of the combined structure of CMRI is that it allows the distinct specialties “to work together in an academic setting” to help advance research in genetics and other areas of cosmetic medicine.
While the University of Miami will continue its skin cream, dermal filler, botulinum toxin and laser and light research trials, CMRI has also begun surgery-based, genetic and stem cell trials. CMRI’s ultimate goal, according to the center’s director Dr. Leslie Baumann, is to find the genes associated with the 16 Baumann Skin Types identified in her book, The Skin Type Solution. CMRI will attempt to make these connections by conducting genetic studies on discarded skin and liposuction fat collected during cosmetic surgeries performed by CMRI surgeons.
Ultimately, Dr. Baumann is confident that CMRI will serve as a blueprint for multidisciplinary collaboration in cosmetic medicine research and that cosmetic surgeons worldwide will benefit from having an unbiased, multispecialty academic based institution to turn to for education and advice.
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Payer & Reimbursement Issues
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MedPAC Considers Recommending 1.1 Percent Physician Payment Increase for 2010
Source: AAFP News Now
Date: 12/16/2008
In anticipation of the deep reductions in physician payment rates projected under Medicare’s sustainable growth rate formula, the Medicare Payment Advisory Commission, or MedPAC, may recommend to Congress a 1.1 percent increase for 2010. Such an increase would come on the heels of an increase in the same amount scheduled for 2009, but MedPAC policy analysts say another increase may be necessary to offset rising inflation and a decline in productivity growth.
A recent meeting of the PAC also concerned payment of primary care physicians, whose services are vitally important but generally less handsomely compensated compared with subspecialties. MedPAC chair Glenn Hathbarck, J.D. pointed out in the December 4 meeting that “productivity opportunities are not uniform across physician practices” and that “in fact, subspecialties seem to have a greater ability to increase their volume for a variety of different reasons compared to primary care.”
As a result, Hathbarck and others with the organization recommend an unspecified increase aimed specifically at primary care providers, a suggestion which echoes the one made in MedPAC’s June 2008 report. Under that plan, money would be taken from subspecialty services and redirected to primary care-focused practitioners, making the increase budget-neutral.
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Medicare e-Prescribing Incentive Begins…but DEA Restrictions Could Cause Problems
Source: Psychiatric Times
Date: 12/01/2008
While e-prescribing seems to be a logical development in the evolution of physician prescriptions, psychiatrists in general have been slow to adopt e-prescription systems. Thus far, the perceived inconvenience of switching to a new system of e-prescriptions for certain drugs while also maintaining paper prescriptions for other drugs has been too great to ignore. The incentive payments proposed under the Medicare Improvements for Patients and Providers Act of 2008, however, may serve as an effective catalyst for such a transition.
Incentive payments of 2% will be paid to those physicians who meet certain e-prescribing reporting requirements in 2009 and 2010. The incentive payments will be set at 1% for 2011 and 2012 and will drop to 0.5% by 2013. While physicians will likely be encouraged by the decreasing incentives alone to adopt e-prescribing systems as soon as possible, those physicians who have not transitioned to e-prescribing by 2012 will suffer a percentage reduction in their Medicare physician fee schedule payment. This reduction will be in effect until a successful transition to e-prescribing is achieved.
In addition to the carrot-and-stick strategy outlined above, the DEA may ultimately provide the greatest incentive for physicians to adopt e-prescribing if it allows physicians to prescribe Schedule II through V controlled substances electronically. By the same token, the DEA’s proposed security requirements for e-prescribing may serve as significant barriers for both physicians and psychiatrists. Physicians, for example, are displeased with the proposed requirement that they present themselves at a “DEA-registered hospital,” a “law enforcement agency,” or the state licensing board to “prove their identity and qualification for prescribing controlled substances.”
The DEA has also proposed a number of complicated software and authentication requirements that many feel will simply baffle physicians and increase the amount of time involved in completing daily tasks. Ultimately, the DEA’s proposed security requirements, such as a lockout function activated on any system that is idle for two minutes, must be balanced against the practical restrictions of a working environment in order to encourage a swift and widespread transition to e-prescribing.
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Credentialing, Licensure, Quality Management
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Continuing Medical Education Profession Launches Certification Program
Source: Medical Meetings
Date: 12/01/2008
Aiming to strengthen their credibility in the face of increased attention from government agencies, Congress, and the press, the National Commission for Certification of CME Professionals recently finished developing and testing a new certification process. After establishing a new non-profit, NC-CME, in 2006, they secured support from the Postgraduate Institute for Medicine, which pledged to give three years’ worth of support, and the North American Association of Medical Education and Communication Companies, which also pledged three years of support. Individuals and organizations donated an additional $95,000 to provide startup funding for the nonprofit, all-volunteer organization.
The organization researched best practices of other professional organizations and identified three key components to a legitimate certification program: education, experience, and formal examination. Following that model, CCMEP applications required summaries of education and continuing education, work experience, and leadership qualifications. Each element was assigned a point value and applicants with enough points were allowed to take the exam.
Despite the diversity of CME professionals’ roles, the new certification aimed to identify core competencies that all members across the board would be expected to understand. The new test was tried out on a group of beta testers in order to get feedback and reassess the exam. The final exam is three-hours, pass-fail, with fewer than 200 multiple-choice questions.
In May, 79 CME professionals took the beta test and then the first official exam in June. Of these, 70 passed. NC-CME plans to construct a new version of the exam for the June 2009 testing period which will reflect developments in the profession, such as new regulations and guidelines. Certification is valid for three years, a standard for certifying organizations.
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Over Half of Obstetric Claims Due to Substandard Care
Source: HealthDay
Date: 12/02/2008
According to a report published in the December installment of Obstetrics & Gynecology, more than half of the typical hospital litigation costs related to obstetric malpractice could be alleviated through the alteration of routine practice patterns.
In an effort to examine specifically how the cost of obstetric malpractice suits might be reduced, Dr. Steven L. Clark, of the Hospital Corporation of America in Nashville, Tennessee, and a team of colleagues analyzed and reviewed 189 perinatal legal claims totaling $168 million to discover whether substandard care caused the given adverse outcome; what practice changes may have avoided the adverse outcome; and whether inadequate documentation led to payment despite the absence of objective evidence.
Dr. Clark and his colleagues concluded that 70% of the individual claims were linked with substandard care—a figure that accounted for 79% of the total $168 million awarded. The study also reported that multiple adverse outcomes may have been avoided through the use of superior practice patterns. Specifically, delivery in a facility with constant obstetric coverage, improved adherence to protocols for high-risk medication and a more conservative approach to VBAC could have helped the physicians avoid cases of non-vaginal birth after Caesarean (VBAC), VBAC-related fetal monitoring and maternal injury. Furthermore, the study indicated that cases of shoulder dystocia could have likely been avoided with the use of a comprehensive standardized procedure.
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Digital Diagnosis: Sorting Good Medical Advice from Bad on the Internet
Source: BusinessWest Online
Date: 01/05/2009
An increasing number of patients are using the Internet to research their own medical issues – and consequently self-diagnose and self-treat – based on online medical information. Experts concede that while the Internet is the easiest place to go for information on health topics, it is best to see a doctor about a health concern before conducting online research. By seeing a doctor first, patients reduce the anxiety caused by worrying about potential diseases as well as the risk of acting on the wrong advice.
Although many providers of online medical advice recommend that users seek a doctor’s diagnosis in person before seeking treatment, it is also very easy for professional-looking websites to trick users into diagnoses and treatments that are not beneficial. Patients need to be extremely careful not only when using these sites, but also when purchasing medicine through online pharmacies. Safe web-based pharmacies should always be located in the U.S., be licensed by the state board of pharmacy where the website is operating, have a licensed pharmacist available to answer questions, and should always require a prescription from a health professional.
A number of reliable sources do exist for patients seeking medical information, including state medical society websites, disease-specific organizations, government departments of health, and academic medical centers and teaching institutions. These sources provide good information that can help patients in their own disease management, allowing them to get better more quickly.
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E-docs: More Physicians Are Communicating Electronically with Their Patients
Source: The News Star
Date: 01/05/2009
Although some doctors assert that the e-mail and online consultations between patients and physicians are the “wave of the future,” surveys show that fewer than one in three doctors nationwide engage in “e-visits” with their patients. The health care industry’s resistance to such online doctor/patient e-relationships is in part due to privacy and access problems, liability issues, and cost concerns for small practices. However, the primary reason for the slow adoption of e-consultations is that most insurers provide no reimbursement to doctors for their e-mail transactions, even though these communications are often in lieu of an office visit.
However, physicians are increasingly embracing the use of e-visits for patients, especially for simple questions, such as blood pressure readings and other routine test results that don’t justify a visit to the doctor but are still of concern to the patient.
Earlier this year, insurers Cigna Corp. and Aetna, Inc. expanded pilot programs that compensate physicians who use a secure Internet site to make virtual house calls with patients. A study by Kaiser Permanente found that patients who used health care providers’ websites were almost 10 percent less likely to schedule an office visit and were also less likely to make phone calls to doctors’ offices.
In an effort to address concerns over patients’ rights during e-communications, the American Medical Association recently released guidelines for physician-patient electronic communications. Experts say that the use of secure encryption software can guard against many additional patient privacy concerns.
In order to begin fostering an e-relationship between patients and physicians, it is suggested that physicians take small steps such as helping patients to make appointments electronically or going online for medication refills, before progressing to communications about non-emergency medical care. These e-communications between physicians and patients can be beneficial not only in terms of increased customer satisfaction, but also due to the fact the physicians have been shown to respond more quickly to e-mail than to telephone consultations.
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Is It Time to Cut the Cord?
Source: Insurance Networking.com
Date: 12/01/2008
Adopting wireless networking and devices for physician group practices is becoming increasingly common as speed, security, and hardware become faster and more adaptable, but the switch from wired to wireless remains challenging. For many practices, networked wireless tablets have streamlined their workflows by allowing doctors and nurses to access electronic medical records on the go. Others rely on a combination of wireless tablets with wired office workstations.
While wireless technology offers many clear benefits, connections can be patchy, leading to dropouts and slow connections, which many physicians find unacceptable. Laptops can also get in the way of physician-patient interactions, although some doctors have gotten around this by mounting the laptops on adjustable carts. Still, the portability of a tablet, as opposed to a workstation in an exam room, allows a doctor to check on a patient’s record before entering the room, removing the potentially awkward process of logging on and looking up a medical record while the patient sits and waits.
Physicians’ preferences tend to vary by specialty. Pediatricians, for example, might worry that a PC in each exam room would end up broken by a child. Some practices, meanwhile, fear tablet computers could be stolen, while for others that tablets can prove impractical because of their screen size. An orthopedic surgeon might need a workstation with a large screen in order to show patients images of their broken bones. Others worry about battery life or data security. Still, combinations of docking stations, thin clients, workstations, and tablets appear to address the majority of concerns for the practices that are determined to go wireless.
Behind the interface itself, practices have started to become more savvy in managing their networks. Upgrading servers, segregating large files, and using data management services have all helped to streamline wireless networks and reduce the problems many practices cite as reasons to put off adoption. As one technology consultant described it, practices often use complaints about the slow speed of wireless networks as a “smokescreen” for resistance to change.
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CAQH Grows Its Effort to Streamline Healthcare Administration
Source: Healthcare IT News
Date: 01/02/2009
CAQH, a nonprofit alliance of health plans and trade associations focusing on simplifying health care administration, reports that The American Academy of Family Physicians, MD On-Line, and Gateway EDI have agreed to use the CAQH Committee on Operating Rules for Information Exchange (CORE) initiative.
Of these new supporters of the CORE rules, MD On-Line, Inc., RealMed Corp., and Summit Medical Group have completed the testing process needed to certify systems and products to meet CORE Phase I requirements.
CAQH developed the operating rules as an all-payer solution that enables providers to use an electronic system of their choice to access patient insurance information before or at the time of service. Already endorsing or supporting the CORE rules are more than 100 industry stakeholders and organizations such as mPay Gateway, Inc., RealMed Corp., Secure EDI Health Group, LLC, and Summit Medical Group.
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Governance for Personal Health Records
Source: Journal of the American Medical Informatics Association
Date: 10/24/2008
Although there has been a great deal of discussion concerning personal health records (PHR), a health care technology that supports patient involvement and the sharing of medical records, the area of PHR governance at an organizational level has not been fully explored. While this technology offers the promise of reducing medical errors, improving disease management, and reducing health care costs, policies concerning the governance of PHR policies are necessary for the protection of patients’ and doctors’ rights.
In order to address the need for governance models, the authors of the Journal of the American Medical Informatics Association have proposed a governance model as a minimum structure for an organizational PHR. The model is adapted from the United States Agency for International Development governance model and includes the following functions: (1) information/assessment capacity; (2) policy formulation and planning; (3) social participation and responsiveness; (4) accountability; and (5) clinical leadership. In addition to the role of the clinician, four other roles are included in the PHR functions. These are a Chief Information Officer (CIO), an informatician, the patient, and a business operations specialist.
When the model is compared to current governance structures in a range of settings, a great deal of variety is found in PHR governance. While their study was limited, the authors assert that improvements in the policy process for personal health records can be improved with a minimum PHR governance structure such as that proposed, in which the five functions and roles recognize clinicians and patients as key stakeholders. It is recommended that further research be conducted to explore how changing PHR governance structures affects policy processes and outcomes.
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Physician Practice Management
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The ABCs of CICs (Captive Insurance Companies)
Source: Unique Opportunities
Date: 12/01/2008
CICs (Captive Insurance Companies) can be very useful tools for physicians who seek insurance against significant risks and would like to gain asset protection, build tax-favored long-term wealth, and discover practice buy-out and estate planning opportunities. A CIC, if created for the appropriate type of practice and established and maintained properly, can be a pivotal component of a physician’s financial plans.
The paramount rule for a CIC is that it must be established as a facility for transferring risk and protecting assets. Ultimately, if the establishment of a CIC is an economically sound transaction, there exists some flexibility in the ways that a CIC can be used. For example, physicians may use CICs to supplement their existing insurance policies, reduce existing insurance, or add coverage for liabilities excluded by traditional general liability policies.
While many doctors self-insure against today’s litigious society with a “rainy day fund” consisting of long-term savings, CICs pose a superior alternative due to the fact that they “enjoy the highest levels of asset protection, can be structured to grow outside the taxable estate, can be structured to layer into a practice exit strategy, and can enjoy extreme income tax advantages as well.” Establishing CICs, however, requires particular expertise, and it is highly recommended that one incur the fees charged by experienced attorneys and insurance managers to achieve 100% policy compliance. Setup costs for CICs are typically around $100,000 while annual maintenance costs are an additional $50,000. Ultimately, the benefits of a properly established and maintained CIC will exceed these costs, particularly for physicians in high-liability and high-income specialties.
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10 Steps to a Better Practice
Source: Medical Economics
Date: 12/19/2008
In order to help physicians improve and control their practices, Medical Economics has reviewed physician and practice management recommendations and developed a list of strategies covering a range of issues.
-The best way to maximize space is to eliminate the waiting room and send patients directly to the exam room area for check-in and check-out procedures.
-It is also recommended that staff lunch breaks are staggered so that the practice can operate more efficiently.
-Instead of phone menus, patients should either be directed to call separate numbers to contact each physician in a practice, or practices should hire a phone operator to answer and direct calls.
-As an intermediate step to paperwork reductions achieved by an electronic records system, practices should organize folders on a computer through the use of a document scanner.
-Physicians should constantly be on the lookout for ways to increase practice efficiency, such as the purchase of additional equipment or use of automated technology to aid staff.
-The entire staff should be involved in brainstorming new ways to improve the practice.
-Staff training should include the use of shadowing of seasoned employees, learning tools such as “dummy charts” for office responsibilities, and checklists of information for new employees that are developed by the staff.
-Bonuses should be tied to quantifiable performances and should be structured so as not to create divisiveness. Praise and recognition should be used in combination with bonuses.
-Successful practices must tailor improvement plans to their specific practice needs and environment.
-Practices should work to evolve with health care, implementing change in small ways on a daily basis.
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How to Make Your Practice More “Green”
Source: Medical Economics
Date: 12/19/2008
Physicians are increasingly adopting greener practices in their offices. While the motivations for environmentally friendly practices vary, many physicians believe that “going green” is a good business practice that results in healthier and happier patients and staff.
Environmental advocates say that even the smallest additions in green practices, including encouraging employees to carpool or adding recycling bins in the office, make a difference in office culture and employee sustainability practices. Furthermore, the American Medical Association passed a resolution in November supporting responsible waste management practices, the use of ecologically sustainable products, and environmentally conscious building practices.
The easiest way for practices to become more environmentally friendly is to “start simple” by reevaluating purchases of office supplies such as paper and cleaning products, turning off lights in unoccupied rooms, decreasing air conditioning use, using high-efficiency light bulbs, and encouraging alternative modes of transportation for office commutes.
New technologies like electronic health records also have great potential to increase care efficiency while decreasing costs to the practice and the environment. However, the costs of purchasing EHR machines are high, and often physicians must “pay before [they] can save.” Alternative environmentally friendly technology practices include performing e-mail and phone consultations to decrease patients’ fuel costs.
Finally, environmental advocacy groups recommend involving the entire office in green practices through the establishment of a “green team.” These teams, groups of employees that lead green initiatives and educate others, are effective in involving the entire practice in the generation of ideas about how to improve sustainability, disseminate information about environmentally responsible behaviors, and sponsor events to raise awareness of greener practices.
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How Harshness Harms Patients
Source: Med League Support Services
Date: 12/01/2007
Healthcare facilities and staff across the country have begun to identify the negative impact of disruptive and abusive behavior exhibited by physicians and nurses on communication, patient safety, employee morale, and turnover. A study of 50 VHA (Volunteer Hospitals of America) hospitals collecting data from over 1,500 participants (primarily registered nurses and physicians) noted that between 73 and 95% of respondents indicated that disruptive behavior sometimes, frequently or constantly results in stress, frustration, loss of concentration, reduced team collaboration, reduced information transfer, reduced communication, and impaired nurse-physician relationships. Equally concerning are the study’s conclusions regarding the effects of disruptive behavior between physicians and nurses on the patients themselves, which include: adverse events, impaired patient safety, reduced quality of care, decreased patient satisfaction, and patient mortality.
A separate study of 2,095 nurses concluded that 88% had encountered condescending language or voice intonation, 87% encountered impatience with questions, and 79% encountered reluctance or refusal to answer questions or return phone calls in the past year. Furthermore, 49% of the respondents indicated that intimidation had “altered the way they handled order clarification or questions about medication orders,” and 75% noted that they asked colleagues to help interpret an order rather than address the prescriber.
The great risks of this intimidation-induced behavior are represented by a legal case cited in this article in which the plaintiffs claimed that their deceased infant developed cerebral palsy after a difficult labor and delivery process. This claim was supported by deposition testimony of the labor and delivery nurses who indicated that “they were concerned about the lack of progress of the mother’s labor, but they were reluctant to voice those concerns to the obstetrician because of the doctor’s well-known tendency to respond negatively to such nursing input.” Ultimately, this resulted in the loss of an infant’s life and a settlement of $1.2 million.
Hospitals and medical centers have begun implementing zero tolerance policies for abusive behavior in the workplace. In some VHA hospitals, for example, physicians are required to sign a conduct contract. In these hospitals, the first instance of a violation leads to counseling, while a second violation results in termination.
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