Court Orders Comparative Hospital Peer Review Records Produced

http://www.medlawblog.com/

In a recent discovery order of The United States District Court, the Southern District of Texas confirms the relevance and discoverability of patient records in credentialing disputes involving comparative peer review, i.e., the peer review disputes where the penalties imposed one physician are dissimilar or unequal to those imposed on others.

In Royal Benson, M.D. v. St. Joseph Regional Health Center, the District Court ordered the production of approximately 1300 patient charts, but divided the cost among the physician and the hospital to prevent undue hardship. Statements of the Court clearly indicate the importance of reviewing the peer review done upon other physicians in these disputes.

Hospital Sues HMO Over Reimbursements

http://www.bakercountypress.com/

The not-for-profit corporation that operates Fraser Memorial Hospital in Macclenny has sued two large health insurance companies to force them to pay the hospital’s going rates for emergency room services. The outcome of the lawsuit filed May 30 against Aetna Health Management and Humana Medical Plan affects out-of-pocket expenses for hundreds of Baker County residents, most of them public employees.
Baker County Medical Services Inc., which manages the hos­pital and adjoining Wells Nursing Home, argues a Florida law that took effect in January 2005 allows it to decide “usual and customary” charges for the emergency room.

The law requires hospital reimbursement by HMOs using one of three criteria: the lesser of the amount billed or the “usual and customary” charges in the community; or, charges agreed upon beforehand by both the hospital and insurance provider.

Flexibility Important In Managing Healthcare Facilities

http://www.hospitalconnect.com/

Flexibility has long been a recognized attribute of the most successful health care facilities. It is described in requests for proposals and project design criteria as a desired feature outcome of the programming, planning and design process.

It offers opportunities for increasing operational efficiency and cross utilization of space. It may also reduce total square footage because it minimizes space, equipment and staff redundancies. However, flexibility is also a subjective term that can translate to a wide range of meanings.

Flexibility must be measured as the physical ability to change to accommodate differing operational or functional requirements. Operational and space standards, such as space allocation rules and size for offices, exam rooms and consultation rooms, have been an accepted methodology for allowing functional change with minimal structural changes.

In most health care organizations, establishing guidelines is beneficial from an operational and construction cost point of view. Similarly, a process can be followed to establish flexibility design guidelines early in the functional space programming process—prior to facility planning and design.

Company Sends Employees To India To Save On Healthcare Costs

http://www.citizen-times.com/

The company’s most ambitious health management initiative is a plan to allow workers and dependents the option of traveling to India for certain medical procedures and sharing in up to 25 percent of the cost savings.

“The cost savings are tremendous, and we would be willing to share that with employees who are willing to do this,” he said.

Overseas treatment options are beginning to draw more attention, said health care consultant Steve Graybill of Mercer Health & Benefits’ Charlotte office, and on-site health clinics are proving increasingly popular with U.S. businesses. “Companies are looking at all options and being creative,” he said.

Drug Utilization Review Implemented In Vermont

http://www.burlingtonfreepress.com/

Beginning today, Vermonters whose health care is paid by the state's Medicaid program won't be taking the much-advertised "little purple pill" -- properly called Nexium -- for gastric acid reflux unless their doctors show that no other medication meets the patients' medical needs.

The new restriction on this brand drug is an example of the state's strategy to curb the growth in the cost of prescription drugs in the Medicaid program. The Legislature and the Douglas administration have struggled in recent years to find enough money to pay the state's share of Medicaid. Overall costs continue to rise in this subsidized health care program for low-income and disabled Vermonters, with a $42 million deficit projected for state budget year beginning July 1, 2007.

About one-third of Medicaid spending in recent years went to pay for prescription drugs. That's a change from the early 1990s when spending for nursing home care ranked first, followed by inpatient hospital care, then pharmacy.

Erectile Dysfunction Drugs Benefit The Rest Of The Body

http://www.medicalnewstoday.com/
When we look at all the different organ systems - the blood, the heart, the lungs, blood flow in the brain - there are hardly any negative side effects. In fact, just the opposite is true. There are beneficial effects for primary pulmonary hypertension, as well as for conditions such as heart failure and lack of oxygen in the heart," said Schwarz. "The only issue is that the data we have are from relatively short-term studies. Viagra has been on the market since 1998 and the other two PDE-5 inhibitors were approved by the FDA in 2003. Therefore, we do not have multi-year follow-up studies. On the other hand, the drugs have been on the market for several years now and there have been no reports of negative long-term effects."

While there are some differences among the three medications, they have many properties in common and work by limiting the activity of the enzyme phosphodiesterase-5, which is found in tissues and vessels of the penis, blood platelets, and smooth muscle of blood vessels. For the treatment of erectile dysfunction, the drugs' constraint of the enzyme's action results in increased levels of cyclic guanosine monophosphate (cGMP) and nitric oxide (NO), biochemicals that promote smooth muscle relaxation and increased blood flow in erectile tissue.

According to the article, PDE-5 inhibitors can be effective in treating erectile dysfunction even for many men who also have diabetes, those who are older, and those who have co-existing ischemic heart disease (reduced blood flow to the heart caused by plaque buildup in the arteries). Furthermore, say the authors, "since PDE-5 is found in smooth muscles of the systemic arteries and veins throughout the body, use

Do Physicians Follow Practice Guidelines? The Study.

http://www.psychiatrictimes.com/

These and other studies demonstrate that there are still many questions about how to develop useful guidelines, how to introduce them into clinical practice, and how to measure their effectiveness. Several authors have examined the process and made useful suggestions about how to resolve these barriers.
CPGs are more likely to be accepted by physicians if they are endorsed by respected professional organizations and colleagues rather than companies and institutions that have a major investment in reducing the cost of care. CPG developers need to test various formats for the guidelines (eg, summaries of recommendations, algorithms, manuals of collected guidelines) before releasing them because physicians apparently prefer some formats over others.4

Mailings of CPGs and formal continuing medical education programs have been reported to be minimally effective in changing clinical practice, perhaps because they are too impersonal. This conclusion is supported by reports that some of the more effective methods of ensuring compliance with CPGs are those that involve guideline monitoring, feedback about compliance, and multiple interactions between experts and clinicians using the guidelines.3,5,8,14 It is worth noting, however, that the successful implementation of an effective CPG does not necessarily guarantee continued clinician compliance with the guideline. 15 This means that there must be some ongoing system that reinforces compliance with the CPG.

Not surprisingly, the clinical habits that physicians develop over years of practice are resistant to significant change without a generous amount of one-to-one contact with experts who are supportive and mentoring rather than critical. Unfortunately, this is a timeintensive and expensive process. Medicine must therefore develop innovative and effective, but less expensive methods of monitoring guideline adherence and providing reasonable feedback to practitioners.

JCAHO Aligns With NFID Standards

http://www.infectioncontroltoday.com

The National Foundation for Infectious Diseases (NFID) applauds the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for announcing its new infection control policy that requires accredited organizations to offer influenza vaccination to staff, including volunteers and licensed practitioners with close patient contact. JCAHO's standard aligns with NFID's ongoing efforts to encourage healthcare institutions to implement policies and programs to increase vaccination rates among health care workers.

"This is an important first step toward improving influenza vaccination rates within the health care community, which will enhance the health and safety of patients in their care and healthcare workers themselves," said William Schaffner, MD, NFID vice president and professor and chair of the Department of Preventive Medicine at Vanderbilt University School of Medicine. "We hope in the future this standard will be expanded to encompass various strategies to increase healthcare worker vaccine uptake, such as signed declination."

JCAHO's standard, set to take effect beginning Jan. 1, 2007, aims to establish an annual influenza vaccination program and improve access to vaccinations on-site. The standard applies to its Critical Access Hospital, Hospital and Long Term Care accreditation programs.

Naval Hospital Passes JCAHO Inspection

http://home.hamptonroads.com/

The Portsmouth Naval Medical Center has again been fully accredited by the Joint Commission on Accreditation of Healthcare Organizations following an unannounced, weeklong review of its practices and procedures last spring.

The surprise inspection was a first for a naval hospital.

Accreditation is for three years and means patients can be assured the center complies with the highest national standards for safety and quality of care, said Rear Adm. Thomas Cullison, the center's commander.

JCAHO, an independent, not-for-profit organization, is the nation's largest and oldest health care accrediting body whose mission is to improve the safety and quality of care, center spokeswoman Deborah Kallgren said in a release

Ohio's Patient Protection Act

http://columbus.bizjournals.com/

The Patient Protection Act was established in 1999 to give consumers a way to challenge insurers who denied their health claims. Since the program began, 2,760 cases have been evaluated and 79 percent of those cases have been ruled in favor of consumers.

Those insured by preferred provider organizations, health maintenance organizations, public employee health benefit plans or traditional insurance are eligible to have their cases reviewed.

An independent review organization working for the Patient Protection Act is required to complete reviews in 30 days, or, for cases involving serious health issues, in seven days. Any decision the review board comes to is binding upon the insurer.

How Patients Covered Under A Managed Care Plan In Pennsylvania Can Appeal Medical Decisions

http://www.phillyburbs.com/

This appeals process isn't open to all of Pennsylvania's 12.4 million citizens. Only people insured by an HMO — health maintenance organization — or other plans in which a member has to go to a primary care physician or some other type of “gatekeeper” for a referral in order to see a specialist.

People insured by “straight,” or traditional, preferred provider organizations do not have the right to the state-mandated appeals process, according to Stacy Mitchell, director of the Pennsylvania Bureau of Managed Care, although the patient could file suit to challenge a rejection.

For people eligible to appeal an insurer's decision, the process works like this:

* An initial appeal — all appeals should be submitted to the insurer in writing — must be reviewed by the plan within 30 days.

* If that appeal is rejected, the patient can request a hearing of the appeal by a plan review committee. The plan has 45 days to hold the hearing, and then must issue a decision within five days.

* If that appeal is unsuccessful, the patient can appeal to the state's Bureau of Managed Care within 15 days. The bureau will send that appeal on to one of the nine independent review organizations — all companies like Imedecs — that are registered with the state, Mitchell said. The independent reviewer has 60 days to issue a decision.

An independent reviewer's decision is binding, within limits. Either party — the health insurer or patient — can sue if things don't go their way, Mitchell said.

There are exceptions to the time limitations at each step in instances where time is critical.

Small Hospitals Lag Behind In IT Support

http://www.modernhealthcare.com/

Use of information technology, especially for storing and exchanging laboratory data, is widespread at U.S. hospitals, but small hospitals without national accreditation have adopted IT systems at about half the rate of large facilities, according to a survey of 650 senior hospital executives. The survey, funded by the CMS and conducted by policy research center Mathematica, Princeton, N.J., found that 88% of the hospitals surveyed were using IT for laboratory results, 59% for clinical notes, 50% for electronic images, 49% for electronic lab orders and 21% for e-prescribing. The rate of use lagged significantly among small hospitals not accredited by the Joint Commission on Accreditation of Healthcare Organizations. For example, 98% of large, JCAHO-accredited hospitals used IT for lab data compared with 48% of small hospitals without JCAHO accreditation.

Federal Law Rules In Medical Peer Review Cases

http://www.law.com/

A federal statute requires the release of a medical facility's peer review records despite state law shielding their confidentiality, the 2nd U.S. Circuit Court of Appeals has ruled.

Clearing the way for the release of peer review records sought for investigations into the deaths of two mentally ill patients at state-administered hospitals, the circuit said the plain language of the Protection and Advocacy for Individuals with Mental Illness Act, 42 U.S.C. §§10801-10851, trumps state law.

The appeal of Protection & Advocacy for Persons with Disabilities v. Mental Health & Addiction Services, 05-1457-cv, was decided by Judges Sonia Sotomayor and Reena Raggi, with Southern District of New York Judge Miriam Goldman Cedarbaum, sitting by designation. Sotomayor wrote for the panel.