Re-certification improves doctors' performance

This week Reuters reported on a study showing that the time elapsed since a primary care doctor's last board certification coorelated with a decline in the quality of care he provides. The study examined the electronic records of patients being treated for hypertension, an important factor in the quality of care.

The expected action by a doctor would be to step up treatment if a patient's blood pressure was high. The expected treatment was highest among internists who and passed their boards the year prior (27 percent). For every decade past doctors' certification dates, the researcher found a 21 percent drop in the possiblity that the doctors would take the expected action.

Patient's Rights Legislation Paying Off for Consumers

Patients whose healthcare treatment is deny by their insurance company have about 50-50 chance of reversing that decision says Lori Andrews, a health law professor at Chicago-Kent College of Law in Parade magazine.

Andrews notes that while the win rate can vary from state to state, about 50 percent of the patients’ challenging their denials are getting them reversed.

In part, this is due to 43 states and the District of Columbia passing Patients’ Bill of Rights acts and the increasing role of independent medical review organizations (IROs) in helping these patients get the treatment they deserve. Often healthcare-plan providers deny treatment based on issues other than the medical necessity of a treatment. Just a few of these reasons include ambiguous plan language, out-of-date exclusions and meeting financial or business objectives at odds with healthcare delivery.

Conflict of Interest In Hospitals Under Growing Scrutiny

This article points out the increased scrutiny of physicians' financial conflict of interest in hospital settings, and how it can lead to over-utilization. It also goes on to point out the opposite argument -- that physicians who are stake holders in a hospital's success tend to act in the best interests of both the hospital and patients.

One point that the article fails to mention is how conflict of interest can impact the objective evaluation of practitioner performance within the context of the hospital peer review process. We hear many medical staff members point to peer review committees that fail to properly scrutinize the performance of fellow practitioners, as a result of financial ties. On the other hand, we are also aware of sham peer review carried out due to economic rivalries.

Whichever situation you have experienced, the fact is that peer review inside the hospital is fraught with potential conflicts of interest, that can be easily identified and eliminated. The key is having the right combination of leadership, by-laws, policies and procedures and a clear commitment to using external peer review when necessary. IROs (independent review organizations) have a clear role to play in eliminating conflicts and improving hospital quality. --AGR

Featured Story January 18, 2008

Physician Financial Relationships, Conflicts of Interest Are Expected to Top List of 2008 Enforcement Targets

Reprinted from REPORT ON MEDICARE COMPLIANCE, the nation's leading source of news and strategic information on false claims, overpayments, compliance programs, billing errors and other Medicare compliance issues.

While some familiar areas are among probable 2008 targets of enforcement agencies, expect the focus to broaden, say experts. So while areas such as hospital-physician relationships will continue to garner scrutiny from the HHS Office of the Inspector General (OIG) and the Department of Justice (DOJ), whistle-blowers and health fraud investigators may also turn their attention to areas such as admission necessity, behavioral health and evaluation and management (E/M) coding.

Lawyers expect physician financial relationships to be at the top of the enforcement list. "The intense scrutiny on physician financial relationships and conflicts of interest will continue unabated in 2008," says former senior OIG attorney Howard Young. "The medical device industry may face the brightest spotlight with ongoing criminal and civil anti-kickback investigations continuing into surgeon consulting and other arrangements. And more so than in past years, this may be the year in which DOJ and OIG pursue enforcement actions against physicians who receive the alleged industry kickbacks."

Errors to cost hospitals

The Wall Street Journal reported this week that big insurers, including Aetna Inc. and WellPoint Inc., are moving to ban payments for care resulting from serious errors during hospital stays, including wrong limb operations and others. Following the federal Medicare program, these insurers are also looking at common medical errors. Medicare announced last summer that beginning in October this year, it will cease paying any extra costs of treating preventable infections or injuries that occur during a patient's hospital stay, such as bedsores, falls, objects left in bodies after surgery, surgical-site infections, blood incompatibility,

While the big insurers are targeting errors for more grievous mistakes, hospitals are concerned that the focus on more common errors will drive up their costs, because they have to implement processes and procedures to prevent such errors. Hospital's also fear this opens the door to expand payment denials for other mistakes.

Click here for a list of procedures that insurers are already denying.

Individual Mandates The Cornerstone of Health Care Reform

This article argues against "individual mandates" as a core principle of the proposals for universal health care coverage that are being implemented by states (including California), and which are being considered by the leading presidential candidates. While I understand the author's concern, I believe that his rationale doesn't hold water. Requiring all citizens to hold health insurance does not either imply or require the development of a large bureaucracy to track and enforce it. What it does do, is get everyone into the nation's risk pool, with the effect of reducing overall costs to our health care system and ensuring they are shared more equitably by all.
What do you think?

Individual Mandates for Health Insurance: Slippery Slope to National Health Care
by Michael D. Tanner
Excerpted from The Cato Institute Website

Proposals for achieving universal health insurance coverage are once again receiving serious attention. Among the ideas attracting bipartisan support is an individual health insurance mandate, a legal requirement that every American obtain adequate private health insurance coverage. People who don't receive such coverage through their employer or some other group would be required to purchase their own individual coverage. Those who failed to do so would be subject to fines or other penalties.

Michael Tanner is director of health and welfare studies at the Institute.
More by Michael D. Tanner

Proposals for an individual mandate respond to a legitimate concern about "free riders," the uninsured who nonetheless receive treatment and pass the costs on to taxpayers or individuals with insurance. In practice, however, an individual mandate is likely to be unenforceable because it would involve a costly and complex bureaucratic system of tracking, penalties, and subsidies.

More important, an individual mandate crosses an important line: accepting the principle that it is the government's responsibility to ensure that every American has health insurance. In doing so, it opens the door to widespread regulation of the health care industry and political interference in personal health care decisions. The result will be a slow but steady spiral downward toward a government-run national health care system.

Read the rest of the article here.

Presidential Candidates On Healthcare

U.S. Presidential Candidates' Health Care Plans: A Side-By-Side Comparison
Posted July 9, 2007 | 03:18 PM (EST)
huffingtonpost.com

By Susan J. Blumenthal, M.D., Jessica B. Rubin, Michelle E. Treseler, Jefferson Lin, and David Mattos*

"The next president of the United States will confront major health policy decisions that will affect the lives of all Americans. With the first of the presidential caucuses and primaries only six months away, the pressure is on for the candidates to provide Americans with their plans to improve the nation's health care system -- and rightfully so. Despite spending over $2 trillion a year on health care -- 18% of the U.S. GDP and twice as much as any other nation -- the United States ranks only 45th in life expectancy and 37th in a World Health Organization study on the performance of national health systems. 1,2 The U.S. federal government currently spends more on health care than on Social Security and national defense combined, the next most expensive items, but Americans get the right treatment only 55% of the time.3 Expenditures on health care in the United States -- already the highest per person in the world -- are predicted to nearly double by 2016, to $4.1 trillion, or 20% of GDP. That means, if this trajectory is not altered, in less than a decade, 20 cents out of every dollar produced in America will be spent on health care. Currently, more than 75% of health care dollars are spent on patients with chronic diseases, yet an estimated 80% of all chronic diseases are caused by preventable factors, such as smoking, obesity, and physical inactivity.4,5 But despite these statistics, less than 5 cents of every health care dollar is spent on prevention and public health.

A recent poll conducted by the Kaiser Family Foundation found health care to be the second most mentioned issue that Americans would like to hear presidential candidates discuss and for the government to address.6 Iraq remains the foremost concern, yet it is important to note that health care tops the list of Americans' domestic priorities. This means that no presidential hopeful can effectively meet the needs of the American people without addressing the essential issues of access, affordability, efficiency, and quality of our nation's health care system. As evidenced in the recent debates, both Democratic and Republican presidential candidates are seeking to demonstrate to the American people an understanding of health care issues and their far-reaching impact on the health, economy, and security of our country."

Read the rest of the article at http://www.huffingtonpost.com/susan-blumenthal/us-presidential-candida_b_55460.html

This article does a good job of articulating the challenges the next President will face in addressing the health care crisis that we currently face. "Access, affordability, efficiency, and quality" are critical issues that must be addressed in the next 4 years, if we are to avoid long-term economic demise.

Independent Review Organizations (IROs) are uniquely positioned to address each of these critical issues, through the delivery of services to all key constituents in the health care payor supply chain, as well as large provider organizations. IROs work with payors to reduce/eliminate over-utilization, while ensuring that consumers receive the health care coverage they deserve. This has a direct impact on health plans' ability to keep cost increases lower, will protecting the integrity of resource allocation decisions. IROs increasingly are helping hospitals to improve practitioner performance and quality, through external peer review.

As active participants in improving health care, we are both concerned and excited by the opportunities that exist for the next President to lead a true paradigm shift in our nation's health care system. It's important that we watch each candidate closely and elect the leader who has proven his/her ability as a change agent, and who is willing to take on the powerful interests that stand firmly behind the status quo.

Software Diagnosis and Quality

According to a 2003 study published in The Journal of the American Medical Association, at least one in 12 patients who die were diagnosed incorrectly. While doctors face some hard to diagnose cases, will turning to technology to bridge this gap make a difference in these numbers, or healthcare quality? Younger doctors are more comfortable with technology and are ready to rely on it. As the doctors from the baby boom retire, will automated diagnosis become more the rage?

Other businesses use software to automate business processes, but we have to question how these same processes are used in medicine, especially for diagnosis. If anything, depending on softare for diagnosing a patient confuses the issue of responsiblity. When there's a wrong diagnosis, who's responsible, the doctor, hospital, software manaufacturer? Should diagnostic software be used only for those cases that are hard to diagnose or easy to diagnose? Will the be capable of learning like doctors? What about a software bug that misdiagnoses a disease that leads to the wrong treatment? What's the role of peer review when diagnosis, and perhaps even treatment, is automated?

The diagnostic use of software raises lots of questions. A Jan. 4 ScienceLine article, "Doctor’s Diagnosis, Version 2.0" touches on some of these questions. -MM

The Poliner Case - A Lawsuit That Could Have Been Avoided With External Peer Review (?)

Most health care attorneys and hospital medical staff professionals have read about the Poliner case in Texas. While some would argue that this case is old news, nevertheless, it is still a landmark case which we can all learn from -- particularly as it relates to the do's and don'ts of effective peer review. The article below is one of many on the subject for those interested. From the outside, it seems amazing how easy it would have been for the hospital and medical staff to avoid this situation altogether, by bringing an IRO (Independent Review Organization) in to perform external peer review at the first signs of alleged practitioner performance deficiencies. Today, many medical executives committees and medical staff leaders are adopting this as a best practice, to ensure fast, objective, "same specialist" evaluation of physician performance. As the fears (and threats) of sham peer review become more prevalent, calling in external resources to provide hospital peer review in sensitive cases can eliminate real or perceived bias. In this case, one could argue that external peer review would have easily prevented this unfortunate situation from every occurring. -AGR

Texas cardiologist wins $22.5 million in suit against Dallas Presbyterian Hospital and three staff cardiologists
October 19, 2006
Shelley WooFrom: Heartwire, TheHeart.org
Dallas, TX - A Texas judge has upheld an earlier ruling against the Presbyterian Hospital of Dallas and three of its cardiologists but reduced to $22.5 million the overall damage award originally granted to a fourth cardiologist, Dr Lawrence Poliner. A jury had earlier decided on the princely sum of $366 million for Poliner after finding in favor of his claims against Presbyterian Hospital and the three physicians on charges of breach of contract, defamation, business disparagement, tortious interference with a contract, and intentional infliction of emotional distress. The defendants are appealing the decision to the United States Court of Appeals for the Fifth Circuit, the hospital announced today. Peer review: Protecting patients or physicians? The case dates back to 1998, when Poliner's cath lab privileges were suspended after a hospital peer-review process concluded that he should voluntarily stop performing cardiac catheterizations due to concerns about his safety record and technique. But Poliner, who sued in 2000, challenged that the so-called peer-review process had been biased, since the panel conducting his review comprised cardiologists competing for patients and referrals at the same hospital. His original lawsuit named 10 physicians as defendants but was ultimately reduced to Dr James Knochel, internal medicine chair, Dr Charles Levin, head of the cardiac catheterization lab, and Dr John Harper, chief of cardiology.

Read the rest of the article at http://www.theheart.org/article/748435.do

Court curbs insurers' ability to rescind medical policies

Here's an interesting article that shows how health insurance payers are under siege...Independent Review Organizations are a perfect solution to helping them do a better job of making benefits decisions, BEFORE a situation like this occurs. Health insurance carriers use IROs to make more informed claims decisions that protect patients and subscribers.

A ruling restricts the ability of California health plans to cancel coverage after patients run up medical bills.
By Lisa Girion
California health insurers have a duty to check the accuracy of applications for coverage before issuing policies -- and should not wait until patients run up big medical bills, a state appeals court ruled Monday.

The court also said insurers could not cancel a medical policy unless they showed that the policyholder willfully misrepresented his health or that the company had investigated the application before it issued coverage.

The unanimous decision by a panel of the 4th District Court of Appeal in Santa Ana is the latest blow to California insurance companies and the way they handle policy cancellations after patients get sick and amass major medical claims.

The insurers' practices are under scrutiny by the state Legislature, the Department of Insurance, the Department of Managed Health Care and the courts. In recent months, state agencies have fined, cited and sued the state's major health insurers for the way they have handled cancellations and treated policyholders.

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