Physician "Pay For Performance" Survey

http://mhanewsnow.typepad.com/

"Physician executives are unsure what to make of pay-for-performance (P4P) programs, according to the results of a new poll. Almost 40% of poll respondents participate in a pay-for-performance program but approximately 60% say it’s too early to tell whether these programs are a fair way to reward physicians for quality improvement.

One physician wrote in the comments section of the survey: “The concept of P4P is correct but we have a long way to go before all of the unintended consequences are addressed and before the true value of P4P is achieved. To achieve the desired aims, P4P programs must remain rooted in quality measurements and only later, after achieving a critical mass of credibility, should cost-efficiency measures be added.”

Malpractice Risk Evaluation For Hospitals

http://lowis-gellen.blogspot.com/

"Health care providers acknowledge that it is often difficult for hospital credential committees to objectively investigate and assess the potential for institutional liability incurred in granting physician privileges. Each hospital governing board has their own process and few instill confidence -- with the hospital board, medical peer review boards or the all-powerful Joint Commission on Accreditation. As a consequence, "negligent credentialing" has become a claim that juries are asked to consider more and more frequently in medical malpractice cases seeking additional damages from health care facilities that granted privileges to a defendant physician. Theresa Hoban, NHC General Counsel, extols the practical utility and objectivity of the process developed by Ms. Karno, as well as its virtue as a proactive rebuttal to claims of negligent credentialing should law suits ensue. "

Hospital Peer Review Found Problems, But...

http://www.mercurynews.com/

"In 2003, a peer review pointed out several key flaws in UC-Irvine's program, including a shortage of surgeons, lack of experienced staff and training and lack of communication with other successful programs.

That peer review also raised the issue of money, in part because of low reimbursements for liver transplant patients covered by Medi-Cal, the insurance for the indigent in California.

``The financial structure for salary support within the Department of Surgery works against the development of a thriving liver transplant program,'' the peer review said."

Message From Texas Insurance Commissioner

http://www.insurancejournal.com/

"Basically, workers' compensation networks will be similar to the managed care networks we see in health insurance, in terms of the regions to be served. The network will serve a particular geographic area. If an employer chooses to utilize a provider network for its workers' compensation claims, then an employee who is injured on the job and lives within the service area will choose a treating doctor from the list of network providers. If the employer does not choose to use a network, or if the employee lives outside the service area, the doctor can be selected from the workers' compensation approved doctor list, just as before.

Workers' compensation is a health delivery system like other health insurance, except that it has the added goal of not just returning to health but also returning to work in some capacity if at all possible. Experienced health care providers dedicated to understanding treatment guidelines, disability durations, and rehabilitation techniques that facilitate timely return to work will be the cornerstone of success.

The network administrators will negotiate with health care providers to build a pool of highly qualified professionals representing all the specialties required to treat workplace injuries. Providers will be able to negotiate their fees and contract requirements, such as procedures requiring preauthorization, while network management handles the administrative functions unique to workers' compensation."

Priorities For One Hospital

http://www.surgicenteronline.com/

"Performance improvement is a top priority of the IOS. Ongoing projects include facility utilization, turnover times, cancellations, narcotics review, patient satisfaction, quarterly medical records review, variance reporting, infection rates, length of stay, transfers and contracted services. “The IOS can be termed a success so far due to the hard work of the staff and management team to create a very supportive, nice environment for the patient undergoing surgery,” says Adams. “The patient and his/her family are the prime focus of each staff member’s day"

Taking Medications Important For Diabetes Patients

http://sev.prnewswire.com/

"In the pilot program, medical, pharmacy and lab claims data was used to identify members who were not reaching recommended long-term blood glucose levels. CPM then reviewed medication utilization patterns to determine if that might be contributing to higher than desirable blood glucose levels. The presence of more than one related illness including hypertension, kidney disease, or high cholesterol was also identified. The physicians for the members participating in the pilot were then sent information on each member, including lab data, medication utilization and hospital or emergency room visits, as well as recommended treatment goals for the member. The physicians were encouraged to review the information and consider whether adding or changing therapy would help the member achieve treatment goals. Members were re-evaluated every six months. The importance of reaching or progressing towards treatment goals was stressed at each subsequent contact with the members' physicians."

Some Insurers Now Reviewing Imaging Requests

http://msnbc.msn.com/

"Blue Cross Blue Shield of Wisconsin will require doctors to get prior approval for some imaging services starting in March 2006 to stem the increasing cost of those services, a move that likely will be unpopular with doctors.

Physicians ordering outpatient CT and PET scans, MRIs, and nuclear cardiology services for Blue Cross members will have to get approval via the Internet or from a call center, said Dr. Lowell Keppel, medical director for Blue Cross. The authorization will be required only for outpatient services and not for imaging scans performed in the emergency room or in urgent care, he said. "

Medical Management Shifts Focus to High-Risk Patients, URAC Study Finds (Complete Press Release)

http://biz.yahoo.com/

A major URAC study finds that medical management companies are using their resources to identify and manage patients who are most likely to incur high-cost care and spend less time on routine care review than in the past.

The finding is one of several detailed in "Trends and Practices in Medical Management," URAC's 2005 profile of the medical management industry. Medical management refers to a broad array of practices, such as utilization management, case management and disease management, which are used to provide oversight to the practice of medicine. The report is based on survey results from 282 medical management companies, along with insights gleaned from telephone interviews and focus groups.

The entire report is available at no charge from URAC in an online format at http://www.urac.org.

URAC is a national leader in medical management quality through its accreditation of hundreds of health plans and medical management organizations, educational programs, research and reports.

"Research into the industry keeps URAC on top of best practices as we promote health care quality through accreditation and other programs," said Alan P. Spielman, president and CEO of URAC. "Our unique approach to accreditation offers companies the flexibility to demonstrate how their organizations meet recognized quality standards across the many modes of medical management."

Enhanced medical information technology with applications for predictive modeling, and identification of high risk members has helped medical management companies to prioritize consumer contact, the report finds. The move towards care coordination and more targeted interventions has resulted in new strategies which allow closer monitoring and guiding of patient care. Many companies include among their practices on-site reviews at hospitals and provider facilities, face-to-face meetings with patients, proactive telephoning, and even home visits.

"That has implications for how medical management companies operate across the board," Spielman said. "It may mean case managers and disease managers have fewer patients, but each patient may have more complicated needs."

National trends detailed in the report reveal a medical management industry in a dynamic period of transition. Its core utilization management and case management activities remain viable and valuable, and disease management is growing rapidly. The drive towards a national health information exchange network will no doubt accelerate the technological transformation already underway within the industry.

"Interestingly, we found that technology has not replaced the one-to-one personal contact that adds value in some medical management areas, particularly in case management," Spielman said. "Most of those we surveyed agreed that there are expanding opportunities for medical management in the years ahead, particularly in the areas of consumer-directed health care, electronic utilization management and predictive modeling."

The survey also found that URAC-accredited medical management companies are more likely to measure and report quality performance and use evidence- based guidelines than non-accredited companies. The finding reveals that accreditation is directly linked to a company's likelihood to promote industry best practices.

"That confirms what many purchasers have known intuitively for years: a medical management company that is accredited is more likely to be transparent in its operations," said Neil Trautwein, assistant vice president of human resources policy for the National Association of Manufacturers, the nation's largest industrial trade association, and a URAC board member. "The survey also found that companies with URAC accreditation in particular measure more and produce more quality reports that companies with other accreditations."

Other key findings include:

* Greater customization: Medical management companies are now using a
more customized approach to the specific needs of clients as they
upgrade and integrate their technology platforms and expand their
scope.

* Use of medical review criteria: Most companies in the industry rely
on a small number of commercial sources for medical review criteria,
and often construct their own criteria by combining sources and
filling in gaps.

* A growing market: Most see expanding opportunities for medical
management in the years ahead, particularly in the areas of telephonic
case management, consumer-directed health care, electronic utilization
management and predictive modeling.

About URAC

URAC, an independent, nonprofit organization, is well-known as a leader in promoting health care quality through its accreditation and certification programs. URAC offers a wide range of quality benchmarking programs and services that keep pace with the rapid changes in the health care system, and provide a symbol of excellence for organizations to validate their commitment to quality and accountability. Through its broad-based governance structure and an inclusive standards development process, URAC ensures that all stakeholders are represented in establishing meaningful quality measures for the entire health care industry. For more information, visit http://www.urac.org

Insurance Fraud Issues In Other Countries

http://healthfraudoz.blogspot.com/

Australia could learn a thing or two from the recent decision in Switzerland. The Swiss government has determined that homeopathy, herbal medicine, traditional chinese medicine, neural therapy and anthroposophic medicine would no longer be covered under basic health insurance. These treatments have failed to meet the health insurance laws that demand therapies be cost effective, suitable and actually work.

Heaven forbid, imagine the gall of the Swiss government to actually insist that a medical treatment work before being covered by insurance. It's a pity the Australian insurers don't follow the Swiss lead.

How can claiming hundreds of dollars for water (aka homeopathic treatment) from a health insurance fund not be considered insurance fraud? Surely, claiming to have the mythical chiropractic subluxations corrected would also qualify as insurance fraud.

Elaborate Health Insurance Fraud Uncovered

http://www.nytimes.com/

"REAL doctors performed real procedures on real patients. The insurance claims were real; so were the surgery centers that filed them. And the money that insurers paid - a total of about $500 million, federal investigators estimate - was most assuredly real.

Hundreds of people, many of them recent immigrants unfamiliar with America's health care system, volunteered to undergo the medical tests and operations. They traveled to surgery centers in Southern California for what would be, in another context, routine procedures like endoscopies, colonoscopies and pap smears. Some traveled, on the clinics' dime, from as far away as Tennessee. Some of them, investigators say, received free or discounted plastic surgery, and others got cash.

Any such payment was and is illegal."

Interrater Reliability Defined

http://www.ojp.usdoj.gov/BJA/evaluation/glossary/glossary_i.htm

"The extent to which two different researchers obtain the same result when using the same instrument to measure a concept."

New Indiana Law Concerning Hospital Errors

http://www.courier-journal.com/

"I don't think people have any clue how many errors happen on a daily basis at hospitals," said Mary Arlien Findling, an Indianapolis attorney who has represented patients and their families in medical-malpractice lawsuits for the past 20 years.

Findling thinks hospitals, not individual caregivers, bear primary responsibility for reducing mistakes, by requiring practices that make them less likely to occur.

"These are system errors. No one should get a 10-times overdose of insulin, the wrong drug or their roommate's drug," she said. "But these kinds of mistakes happen on a regular basis."

JCAHO 2006 Critical Access Hospital and Hospital National Patient Safety Goals

http://www.jcaho.org/general+public/patient+safety/06_npsg_cah_hap.htm

Goal 1 Improve the accuracy of patient identification.

1A Use at least two patient identifiers (neither to be the patient's room number) whenever administering medications or blood products; taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures.

1B Not applicable.

Goal 2 Improve the effectiveness of communication among caregivers.

2A For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the order or test result "read-back" the complete order or test result.

2B Standardize a list of abbreviations, acronyms and symbols that are not to be used throughout the organization.

2C Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values.

2D Not applicable.

2E Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.

Goal 3 Improve the safety of using medications.

3A Retired in 2006.

3B Standardize and limit the number of drug concentrations available in the organization.

3C Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the organization, and take action to prevent errors involving the interchange of these drugs.

3D Label all medications, medication containers (e.g., syringes, medicine cups, basins), or other solutions on and off the sterile field in perioperative and other procedural settings.

Goal 4 Not applicable.

Goal 5 Retired in 2006.

Goal 6 Not applicable.

Goal 7 Reduce the risk of health care-associated infections.

7A Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.

7B Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection.

Goal 8 Accurately and completely reconcile medications across the continuum of care.

8A Implement a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list.

8B A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization.

Goal 9 Reduce the risk of patient harm resulting from falls.

9B Implement a fall reduction program and evaluate the effectiveness of the program. Note: Replacement for 9A

Goal 10 Not applicable.

Goal 11 Not applicable.

Goal 12 Not applicable.

Goal 13 Not applicable.

Goal 14 Not applicable.

Outsourced Medical Billing: A Challenge

http://www.capstonemedicalbilling.com

"Some physicians have been burned by doing business with medical billing companies that may have very good intentions and promised great results, but simply didn't have the on the job experience to handle the myriad of unusual circumstances, unexpected situations, and fast moving changes (some coding numbers can change many times in one year, and a wrong coding number means delays in reimbursements) that can occur in this industry.

Outsourcing medical billing is a huge step for many practices, but by asking the right questions, you can ascertain how much experience and how much faster your claim payments will be reimbursed to your office. Find out how the medical billing company charges for their services and what services are included with that fee."

No Federal Medical Review Privilege

http://federalcivilpracticebulletin.blogspot.com

"The Supreme Court has several times refused to recognize a privilege when doing so would inhibit a federal investigation. Furthermore, the federal interest in this investigation is to enforce laws against health care fraud, an interest other federal courts have found sufficiently strong to refuse to recognize a federal medical peer review privilege. Additionally, this decision comports with the findings of the vast majority of federal courts that have faced this issue in other contexts. As such, the government has shown sufficiently that the costs of withholding the documents would outweigh the benefits of recognizing a medical peer review privilege in the context of a federal criminal investigation. Therefore, the Court will not recognize a federal medical peer review privilege under Fed.Rules Evid.Rule 501, 28 U.S.C.A. (citations omitted)."

What Is A Disruptive Physician?

http://doctorrw.blogspot.com/

"Of course there are occasional examples of physician behavior clearly detrimental to patient care such as intoxication, sexual impropriety and threatening or intimidating behavior so severe as to preclude an effective working relationship among staff. Such episodes require an organized, explicit institutional response. The notion of a disruptive physician policy to deal with these situations is sound. But how do you define disruptive behavior? Greg Piche in his Health Care Law Blog recently remarked “The definition of what constitutes disruptive behavior in most of these policies is left so inordinately broad and so diaphanously vague as to render them effective tools for silencing responsible criticism….” His examples of behaviors that could be considered disruptive are concerning; having a disagreeable personality or willingness to speak out against the administration could perhaps result in a disciplinary proceeding."

Hospital Peer Review Battle In Florida Courts

http://orlando.injuryboard.com/

"A West Palm Beach, Fla., attorney has won a ruling declaring that the state Legislature's implementing law for last year's Patient Right to Know ballot initiative is unconstitutional because it fails to provide full public access to records on medical errors.

The ruling is at least the second recent Florida circuit court decision in favor of medical malpractice plaintiffs who want to use the new constitutional amendment to obtain previously confidential hospital records on medical errors and physician discipline."

Medical Journal Articles Might Be Ghostwritten

http://www.post-gazette.com/

"It's an example of an open secret in medicine: Many of the articles that appear in scientific journals under the bylines of prominent academics are actually written by ghostwriters in the pay of drug companies. These seemingly objective articles, which doctors around the world use to guide their care of patients, are often part of a marketing campaign by companies to promote a product or play up the condition it treats.

Now questions about the practice are mounting as medical journals face unprecedented scrutiny of their role as gatekeeper for scientific information. Last week, the New England Journal of Medicine admitted that a 2000 article it published highlighting the advantages of Merck & Co.'s Vioxx painkiller omitted information about heart attacks among patients taking the drug. The journal has said the deletions were made by someone working from a Merck computer. Merck says the heart attacks happened after the study's cutoff date and it did nothing wrong."

Feds Investigate Hospital Procedures

http://www.ocregister.com/

"While July's inspection focused solely on issues related to the liver transplant program, this time around the inspectors, who include nurses, pharmacists and doctors, are attempting to lay the entire hospital and its policies and procedures bare. Some state inspectors are part of the team, working under contract for Medicare."

Medical Review Shows CPPS is a Syndrome Rather than a Specific Disease – Prostatitis Foundation (Press Release)

The Prostatitis Foundation today cited a 2005 medical review that shows that Category III chronic prostatitis/chronic pelvic pain syndrome, also known as CPPS, is a syndrome rather than a specific disease and that the cause can be multifactorial.

The review, entitled "Multimodal therapy for chronic prostatitis/chronic pelvic pain syndrome" and published by Current Urology Reports, 2005 July, 6(4):296-9, also said that monotherapy has often proven ineffective in clinical practice.

"Multimodal therapy, which sequentially or simultaneously can address infection, inflammation, and neuromuscular spasms appears to have the greatest potential for symptom improvement, especially in patients with longstanding symptoms" said Dr. Shoskes in the review.

Dr. Shoskes is a urologist at the Glickman Urological Institute and the Cleveland Clinic Foundation. His clinical subspecialty areas are renal transplantation, chronic prostatitis and interstitial cystitis.

Utilization Review In The Public Sector

http://triad.bizjournals.com/

"Under the agreement, the two agencies will also provide Medicaid utilization review services for their clients -- patients with mental health problems, developmental disabilities and substance-abuse problems. In utilization review, an outside party reviews what providers have charged Medicaid in the course of treating a patient to ensure the services provided meet Medicaid guidelines.

The heads of both nonprofit agencies issued a statement that said the partnership "is practical due to the geographic contiguity of our counties, as well as the similarity of our populations and demographics."

How A Hospital Cut Down On Medication Errors

http://www.advocatepress.com/

“Medication Reconciliation” is defined as a formal process of obtaining a complete and accurate list of each patient's current home medicines - including name, dosage, frequency and route - and comparing the physician's admission, transfer, and/or discharge orders to that list. The process involves three steps:

Verification: collection of medication history, usually done by a nurse.

Clarification: ensuring the medications and dosages are appropriate, usually done by a pharmacist.

Reconciliation: documentation of changes in the orders, usually done by a physician.

Florida Hospital Grades Posted Online

http://www.floridacomparecare.gov/

"When it comes to your health care, transparency of useful information is important. The Agency for Health Care Administration's (AHCA) consumer website includes performance data and information on selected medical conditions and procedures in Florida's short-term acute care hospitals and ambulatory (outpatient) surgery centers. This information is not designed to offer medical advice, and is only one avenue to assist you in making well-informed health care decisions. Where appropriate, the data is severity adjusted utilizing the 3M Health Information Systems software, which is designed to provide more valid comparisons among facilities"

Medicare Part D: Regulatory Relief

http://www.medicalnewstoday.com/

"Physicians worked for a long time to secure the MMA regulatory relief provisions in order to help bring more fairness and due process to Medicare audits and reduce unnecessary paperwork.

Under the MMA provisions, if physicians are audited by Medicare carriers and told that they must repay so-called "overpayments," they will be able to wait until their appeal has been heard before the carrier can demand repayment. In addition, repayments can be made in installments instead of having to be made all at once in 30-60 days.

The law also places limits on carriers’ use of "extrapolation," which is the process by which they multiply errors made on a small number of claims to calculate enormous overpayment demands.

Medicare officials have been working to address longstanding concerns about excessive documentation requirements for evaluation and management services.

The MMA builds upon this effort by preventing the Medicare program from imposing any new evaluation and management documentation guidelines for physicians as a national standard until several pilot tests have been completed.

The pilot tests would have to demonstrate that any proposed new guidelines succeed in identifying clinically relevant documentation while decreasing non-clinically pertinent and burdensome documentation time and content."

Medicare Part D: Pharmacist & Physician Perspectives

http://www.mydna.com/

Physicians generally view the new plan in a positive manner given the escalation in cost for many drugs, and the fear that without such a plan, many seniors could not afford necessary medications. Still, they lament the problems individuals are experiencing as they learn of the plan details.

"The new Medicare prescription drug program is a great step forward in helping assure that seniors and other Medicare beneficiaries get the medicines they need," said myDNA's Chief Medical Officer William Rice, M.D.

"Unfortunately, the complexity of the new program creates significant confusion and uncertainty among many beneficiaries," he said.

Pharmacists also have mixed reviews on the new plan.

"Medicare Part D is frustrating for both health care professionals and Medicare beneficiaries. I think most people are turned off by Medicare Part D because it is so confusing and overwhelming." said Pharmacist Jodi Klocek, a member of myDNA's Medical Advisory Board.

"Medicare-eligible beneficiaries should ask their physician or community pharmacist about Medicare Part D and continue to access information about this new benefit," she said.

Review of Online Medical Websites

http://www.baltimoresun.com/

"Among the sites run by teaching hospitals, my favorite is the Mayo Clinic's, mayoclinic.com. It has clear information on many diseases and carries the two seals of approval you should look for on any medical Web site, one from Health on the Net, healthon net.org, and the other from an accreditation organization, URAC, urac.org. Both of these independent, nonprofit organizations use specific criteria to vet information. At URAC, Web site creators have to pay $7,000 to go through the accreditation process, though this does not assure accreditation. Health on the Net does not charge.

Many medical schools also have Web sites, though some of these are better at promoting their own doctors or research than providing general medical information. One good one is Harvard's. Go to hms.harvard.edu and then click on "consumer information," then "intelihealth." The site is owned by Aetna, but Harvard Medical School has editorial responsibility. The site has encyclopedic health information, as well as reviews of breaking medical news stories and an "ask-the-expert" feature that answers selected e-mailed questions. "

What Happens When A Hospital Doesn't Follow IRO Recommendations (Press Release)

http://communitydispatch.com/

Inspector General Daniel R. Levinson announced today that the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) notified Miami’s South Shore Hospital and Medical Center (South Shore) of an impending exclusion from Medicare, Medicaid, and all other Federal health care programs. Today’s action resulted from South Shore’s material breach of the terms of a corporate integrity agreement (CIA) it negotiated with OIG in 2002, as part of the resolution of a False Claims Act case against the hospital.

South Shore has 30 days to demonstrate that it is in compliance with the obligations of the agreement, that it has cured the breach, or that it is timely pursuing cure of the breach with due diligence. If South Shore fails to do so, OIG may exclude the hospital from participation in Federal health care programs for its material breach. The hospital has the right to request a hearing before an HHS Administrative Law Judge, with a right to further appeal to the HHS Departmental Appeals Board.

“The decision to issue a proposed exclusion letter to South Shore was made after careful consideration of the facts and circumstances regarding the actions of this hospital,” said Inspector General Levinson. “In the majority of cases, provider organizations comply with the terms of the CIA. However, South Shore’s repeated and egregious failure in this case to abide by the terms of its CIA requires OIG for the first time to seek exclusion for such a violation,” Levinson concluded.

Specifically, South Shore repeatedly failed to timely submit complete and accurate implementation and annual reports, and failed to implement all of the Independent Review Organization requirements of the CIA, which called for particular types of cost reporting reviews and engagement procedures. South Shore also failed to notify OIG, as required, of its sale to new owners, who are also subject to the terms of the CIA.

Prior to this action, OIG analyzed the potential impact on beneficiaries if South Shore (which is not currently accredited by the Joint Commission on Accreditation of Healthcare Organizations) were to be excluded. OIG determined that numerous accredited hospitals existed within a 10-mile radius of South Shore and therefore beneficiaries would not be adversely impacted by the exclusion.

In its May 9, 2002, False Claims Act settlement, the hospital agreed to pay the United States $937,000 to settle allegations that it overcharged Medicare by submitting false cost reports for unallowable costs associated with its Guardianship Health Plan. The Settlement Agreement also resolved OIG’s Civil Monetary Penalties Law and permissive exclusion authorities. Although South Shore entered into a comprehensive 5-year CIA with OIG, it has a long history of noncompliance, which in November 2003 led to OIG’s imposition of a $50,000 Stipulated Penalty on
the hospital for violating the terms of the CIA.