It's imperative that healthcare providers team with patients to determine the ultimate medical mission.
This article appears in the September issue of HealthLeaders magazine.
Muna Salman, MD, a palliative care hospitalist at the 220-bed Rush Copley Medical Center in Aurora, Ill., recalls listening as an elderly, gravely ill patient talked about her dream of being free of pain, even as her family talked of complicated procedures that held no promise of giving her more days. "No more," the patient said, hopeful that she could simply spend her remaining time at home. Salman walked out of the room and teared up, filled with humility over the patient's resolve and a sense of professional satisfaction in knowing, "We helped her on her path."
Mohana Karlekar, MD, medical director of the palliative care program at the 832-bed Vanderbilt University Medical Center in Nashville, recalls a 90-year-old patient who had "terrible heart failure" and was interested in transitioning to a comfort-based approach. The patient was anxious to begin this conversation but afraid to get bad news. He wasn't ready for any in-depth conversations just yet. "Providing too much information when a patient is not ready can result in moral distress. One needs to communicate information in a way that's sensitive to his needs," says Karlekar. "Some may be willing to engage. Some may not."
Timothy G. Ihrig, MD, MA, medical director for palliative medicine at the 132-bed UnityPoint Health-Trinity Medical Center in Fort Dodge, Iowa, recalls treating a 43-year-old woman who had ovarian cancer and was later diagnosed with breast cancer. She was extremely depressed. Ihrig talked with her about a complicated treatment plan. In a sense, "I walked a journey with her, framed it in a real-world perspective." She pursued her treatment plan vigorously. After a series of procedures and treatments, she's now "traveling the world, a new person," he says.
Turmoil, uncertainty, calmness, and serenity are wrapped around the medical mission in end-of-life care. The physicians' experiences reflect those of countless others and are illustrative of the uncertainty in the complicated area of healthcare involving critical conditions and those patients nearing death. Physicians and hospitals struggle over the question of care: Should another test be done? Should there be another surgery? It's never an easy decision, involving a complex mix of medical considerations, the desires of patients and families, and ethical concerns.
"We don't always deal with the issues of death and dying very effectively in our culture," says Kathleen Potempa, PhD, RN, FAAN, dean of the University of Michigan School of Nursing. "When you have a very seriously ill person, a physician is trained to do everything to save a life and the family may be hoping that one more thing will be the magic bullet, but that isn't the reality.
"We don't step back and think of it from a humanistic perspective—we are trained healers, and we forget that dying is a natural part of the human experience," she says. Too often, "we're not letting the person align with the spiritual side of letting go, physically, emotionally, and psychologically, which is important for a peaceful death."
Although hospitals, health systems, and physicians have been struggling with initiating significant conversations with patients and families about chronic illness and end-of-life care, that is changing. At some organizations, clinicians, encouraged by executives, are holding end-of-life conversation more openly and more often. Others say there's a long way to go. As far as healthcare leaders are concerned, the conversations couldn't happen any sooner.
Cost factors
By 2030, the number of people in the United States over the age of 85 is expected to double to 8.5 million. Hospitals are filling rapidly with seriously ill and frail patients. These patients, many with chronic conditions, are bouncing back and forth between nursing homes and acute care hospitals, which shows the need for better coordination and discharge planning.
A 2009 New England Journal of Medicine study found that Medicare payments for unplanned rehospitalizations totaled $17.4 billion in 2004, and that one in five Medicare patients was rehospitalized within 30 days of discharge. A 20% decline in potentially preventable readmissions (from 12.3% to 9.8%) would reduce readmission spending by more than $2.5 billion, according to the Medicare Payment Advisory Commission's March 2013 report to Congress.
As more healthcare facilities seek to know a patient's wishes for end-of-life care, that emotional path also is being made against the cool backdrop of the highest healthcare costs: Care for chronically ill and gravely sick patients is inexorably linked to expensive procedures or expensive stays in the intensive care unit. While hospitals have begun making inroads in controlling spending on end-of-life care, they still fall short in holding back expenses, according to the Dartmouth Atlas Project, which studies variations in health spending.
From 2007 to 2010, the use of hospital services in the last six months of life "fell significantly," with a 9.5% decrease in hospital days per patient and an 11% decrease in deaths. However, Medicare spending per patient in the last two years of life rose from $60,694 to $69,947, a 15.2% increase during a period when the consumer price index rose only 5.3%, the project notes.
"The cost of healthcare in the country is bankrupting the country, and we've got to get our minds around the cost of care," says Chris Van Gorder, FACHE, president and CEO of the 1,323-bed Scripps Health in San Diego. "We need to manage costs much more effectively. The question we always have is, 'Is what we are doing at the end of life the most appropriate thing to do, and the most compassionate thing to do?'
"From an economic and clinical standpoint, the most money spent is in the first five years of life and the last five years of life," Van Gorder adds. Expenses also mount with overtreatment, readmission, and unusually extensive lengths of stay, he says.
End-of-life care also is widely variable in terms of cost. A Dartmouth Atlas study of nearly 3,000 hospitals found significant differences in spending on patients who died between 2001 and 2005 after receiving care. While the Mayo Clinic had the lowest cost at $53,432 per patient, UCLA and New York University had costs of between $90,000 and $100,000. High cost centers also had greater lengths of stay and more procedures, such as doctor visits and consultations.
Although palliative care is seen as cost-effective, the benefit derives not from how much a healthcare institution generates in revenues, but from how it avoids expenses, Van Gorder says. Reimbursements are lagging in palliative care, prompting hospitals to be innovative with their programs, such as taking steps to team up with hospice programs or nursing facilities to curtail costs and reduce 30-day readmissions.
Care alternatives
To alleviate the most heart-wrenching and costly aspects of end-of-life care, healthcare executives are increasingly implementing palliative and hospice care programs for chronically ill patients or those nearing death. Palliative care has been shown to both extend life for patients and reduce healthcare expenses. Palliative care programs focus on the chronically—but not necessarily terminally—ill.
Such efforts are growing in popularity as hospitals form multidisciplinary teams who work to care for patients to relieve the suffering, pain, depression, and stress that often accompany chronic illness. Those teams include physicians, nurses, psychologists, spiritual counselors, and social workers. Unlike palliative care, hospice care is focused on improving quality of life for terminally ill patients with a prognosis of less than six months to live.
As many as 90% of major hospitals with more than 300 beds have palliative care programs, says R. Sean Morrison, MD, director of the Hertzberg Palliative Care Institute at the 1,171-bed Mount Sinai Hospital in New York City and director of the National Palliative Care Research Center.
Morrison is a longtime advocate of palliative care and has been one of the most prolific researchers into its impact on healthcare. He has focused on studies of the economic impact of patients facing serious illnesses that he says account for a disproportionately large share of Medicare spending.
In one of his most significant studies, Morrison examined four New York hospitals between 2004 and 2007 and found that the average patient who received palliative care incurred $6,900 less in hospital costs during a given admission than a matched group of patients who received usual care. The reduced costs included $4,098 less in hospital expenses per admission for patients discharged alive compared to non-palliative care, and $7,563 less for patients in palliative care who died in the hospital.
"Every study has shown people survive long or longer when they receive palliative care. It doesn't shorten life; it extends life," Morrison says. "By matching patient goals to treatment and essentially ensuring patient-centered care, we eliminate misutilization and waste."
The number of palliative care programs in American hospitals has grown substantially over the past decade, according to an analysis by the Center to Advance Palliative Care, which advocates more palliative care programs. Between 2000 and 2008, the number of palliative care programs in hospitals with 50 or more beds increased from 658 to 1,486, for a total increase of 125.8%, the center reports.
For hospitals, palliative care is relatively inexpensive, has a relatively low start-up investment, and has increasing ROI potential because of anticipation that more patients—the elderly and those with chronic conditions—may be suited to such care, the CAPC states. Such programs can have an immediate impact on overall resource usage, including ICU utilization, when patients in palliative care decide to steer away from expensive procedures, according to the center.
Program development
While the trend for such programs clearly is underway, there still is confusion among physicians, hospital leaders, and patients as they struggle to define exactly what palliative care and hospice care is. Some complain bluntly that there are physicians who don't know the difference and have made little attempt to understand the meaning behind the terms. Some healthcare leaders are describing their elevated care for the chronically ill and dying patients as "advance care planning," which is an emphasis on improved coordination including involvement of the patient and his or her family.
Terminology aside, many hospitals are expanding the scope of their palliative care programs. Some, such as the Vanderbilt University Medical Center in Nashville, are expanding programs beyond primary care to other service lines, including oncology and cardiology.
The 325-bed Gundersen Health System in La Crosse, Wis., extends palliative care to outpatient services, while inside the hospitals, its hospitalists are becoming more involved in leadership of palliative care programs. Citing a need to improve patient and family education about palliative care, hospitals are tapping into educational programs and using tools such as videos to increase awareness about end-of-life care.
Less than a decade ago, hospitals were just scratching the surface on developing palliative care programs. Yagnesh Patel, MD, vice president of medical staff at Chandler Regional and Mercy Gilbert Medical Centers in Chandler, Ariz., recalls in 2004 when the hospital's former CEO "asked the group who knows anything about palliative care."
One hospital official "chimes in, I know a little bit." The CEO responded, "You are it," meaning he should direct the program. That set in motion a small palliative care program for Chandler Regional. When Mercy Gilbert Medical Center was built in 2007, it also started a palliative care program. The hospitals have a joint palliative care program that includes inpatient beds and a staff of 11.
Over the past several years, the number of inpatient visits for the hospitals' palliative care programs increased steadily, from 2,800 in 2009 to 3,212 in 2012, and also now averages 52 referrals a month to the outpatient palliative care program, Patel says. By coordinating the palliative care and hospice program, the hospitals also have reduced readmission rates. The palliative care readmissions rate was listed at 1.5%, compared to the overall hospital rate of up to 10%, he adds.
A growing elderly population in Arizona and a lengthy list of congestive heart failure and cancer patients prompted the hospitals to begin their palliative care specialty. Before the palliative care programs were launched, there "was a lack of symptom management and support was lacking," Patel says. "There wasn't enough advocacy for patients' needs, and it wasn't addressed in the acute care setting. As a result, the patients ended up back in the hospital.
"We believed it was necessary to enhance the transition between hospital and home, and we developed an outpatient program two years ago. Once we began our focus on palliative care instead of end-of-life, community hospices came to us and asked how they could support our endeavor to help this special population who were falling through the cracks." Patel says medication reconciliation and illness education are key components of any hospital's plan to reduce readmissions.
Integrated programs
"It's time consuming when you are doing it," Timothy Corbin, MD, medical director for hospice and palliative care services at Scripps Health, says of palliative care. "In a hospital when you are in crisis mode and there's a sudden change in someone's health status, everybody is scrambling, but palliative care needs time. The patient doesn't always hear what's being told and you have to take the time to have these conversations."
That's why it's important to have an integrated program that involves hospitals, medical groups, and home- and community-based services, especially for patients with late-stage chronic illness, says Brad Stuart, MD, CMO at Sutter Care at Home, which is part of the 24 hospitals and more than 5,000 physicians affiliated with the Sutter Health system based in Sacramento, Calif.
Sutter has included care management and palliative services under the umbrella of the Advanced Illness Management program that Stuart and his team created for what he terms a "vulnerable and growing population." While palliative care is often focused on the "relief of symptoms and suffering," Stuart says, "our focus is much more comprehensive and positive."
Multidisciplinary teams that include physicians, nurses, social workers, therapists, and nutritionists are part of Sutter's palliative care program. Various elements focus on the specific needs—and wants—of patients. While physicians often outline the medication needs for patients, the AIM program always considers "what does the patient want?" Stuart says. It's the "little things" that matter that are too often lost in traditional medical care, he adds.
"We are taking more seriously those little things that a patient wants or needs," Stuart says. "It's like the patient walking to the dinner table with their family, or seeing a granddaughter graduate from high school. We make those personal goals the priority and then design care plans to match those. That causes a very interesting shift in priorities, not only for the care team but for people being cared for."
To develop its AIM program, Sutter received $13 million from the Center for Medicare & Medicaid Innovation under a three-year grant. The money came after Sutter's Sacramento region showed positive outcomes from its AIM program, such as reduced hospitalizations and improved care transitions.
The AIM program has had substantial impact, Stuart says. In a two-year review of 185 patients in the program, those who lived at least 30 days had 68% fewer hospitalizations than similar patients who were not in AIM. Those who lived 90 days had 63% fewer hospitalizations, according to Stuart.
There were also significant cost savings, he says: The average savings per patient was more than $2,000 per month. Of all patients who entered the program, about two-thirds went to hospice with longer lengths of stay in hospice than those who had not been enrolled in AIM.
Patients welcome the program, Stuart says. Of all patients offered enrollment in AIM, only 2% have refused.
Early outreach
Gundersen Health System has initiated a pilot program with the Centers for Medicare & Medicaid Services that allows prospective patients with advanced illnesses and their families to consider outpatient palliative care even before they are admitted to the hospital. Gundersen officials say they have succeeded in changing the mind-set of those within the health system and the community by embracing discussions about end-of-life care that are not about dying.
Since establishing the program, Gundersen has rates among the highest in the nation for advance care planning, with unusually low end-of-life hospital costs. It has 95% of its severely or terminally ill patients on an advance care plan, compared to the national average of 50%. In addition, 98% of the time, Gundersen has had consistency between the known care plan and the treatment provided, compared to the national average of 50%.
"Our goal is to try to enroll patients much earlier, identifying them much earlier in their care," says Bernard "Bud" Hammes, PhD, director of Medical Humanities and Respecting Choices for Gundersen. He also chairs the institutional review board and ethics committee at Gundersen. Essentially, the hospital works with patients and their families to integrate patient choices and direction before a time when the patients can't make their own medical decisions.
"We believe people want to stay functional in their homes," Hammes adds. "That's the goal. It's not only better for the patient but also turns out to be cheaper for healthcare. You invest this time, it's relatively low-tech and low-cost care, you prevent three days of hospitalization, and you come out ahead. That's not too difficult to figure out. We realize there are limits to how much a patient wants."
Service line focus
Palliative care programs traditionally have focused on cancer patients. Vanderbilt University's palliative care program, however, sees a diverse patient mix, including oncology, trauma, chronic heart failure, ICU, and dementia patients, says Karlekar, head of the palliative care program.
"Vanderbilt's palliative care program consists of both inpatient and outpatient services. The inpatient services consist of a consultative service and a dedicated inpatient palliative care unit. It includes six physicians, two nurse case managers, a social worker, a chaplain, and three nurse practitioners. A key element of this team is that we provide multidisciplinary care to our patients and families," she says.
The palliative care team strives to help patients develop a plan of care that is consistent with their values, is medically appropriate, and assists with symptom management and the transition of patients to hospice, Karlekar says.
Vanderbilt's palliative program began in 2005 with a small consultation service and expanded over the past several years, she says. The service initially received approximately 35 new consultations per month and now sees on average more than 160 new referrals monthly. While the bulk of referrals are medicine-geriatrics patients and those from the medical ICU, approximately 10%–15% of referrals come from oncology, another 10% from heart failure, 10%–12% from trauma, and 10%–15% from neurosciences.
Outpatient focus
Although much hospital work is moving toward outpatient, palliative care has been slow to adapt. Some hospitals, however, are initiating palliative care programs on an outpatient basis, often with cooperative agreements with private palliative care programs and hospices.
That's what the Gilbert and Chandler hospitals have been doing, says Donna Nolde, RN, MA, MS, CHPN, CEC, of the palliative care unit.
The hospitals' outpatient palliative care program is coordinated with community organizations, agencies, and a hospital foundation, Nolde says. Two years ago, the outpatient program was established. "There was a big realization that chronically ill patients were going home without any resources, sometimes with no one to check on them. They were not truly understanding their medication regime or getting follow-up care with a physician," she says.
The hospital has relationships with hospices, community organizations, and skilled nursing facilities for the so-called "transitional" palliative care plan on an outpatient basis, especially for formerly hospitalized patients, Nolde says. A major element of the program involves follow-up visits and calls from nurses when patients leave the hospital. Within 24 hours of a discharge, there's a visit by a nurse or physician and weekly visits will continue for at least four weeks and then as long as needed. As a result, "patients can leave the hospital a little sooner than they might otherwise," Nolde says.
ACO focus
Collaboration with community providers is of growing importance as hospitals develop accountable care organizations that include palliative care programs. That has been evident at the UnityPoint Health-Trinity Medical Center. The hospital is one of the CMS Pioneer ACO models. The organization covers a region in northern Iowa with a population of about 100,000.
In a three-year review, the UnityPoint Health-Trinity Medical Center palliative care program has resulted in a 67% reduction of overall costs for chronically ill patients: a savings of $800,000 the first year, $1.8 million the second, and $2.1 million the third year. Under the ACO, the 30-day hospital readmission was reduced by 43%, according to Ihrig, the medical director for palliative medicine.
Despite the steady improvement, the process isn't always easy to carry out. "Between 2005 and 2010, UnityPoint Health grew to four different regional palliative care programs," says Lori Bishop, RN, CHPN, clinical innovations adviser. "We took the opportunity at that time to standardize our definitions and unify our programs. Because of limited reimbursement and the system's investments, we began tracking palliative care metrics—which included operational, financial, clinical, and customer satisfaction—across all our regions."
Those problems are inevitable, adds Ihrig, because "even though we are so far ahead of the curve, we are in the preadolescence of palliative care as a subspecialty. We're still working downstream." It's important that the health system leadership works to engage physicians within the ACO. There is still much confusion about palliative care. "Even though our system is still hanging that shingle out for palliative care, there is misunderstanding what it is. It's not a 'death panel' issue."
The big picture
Looking at the big picture of end-of-life care is what Van Gorder says Scripps Health wants to do. That's one of the reasons it outbid another hospital to purchase a hospice facility through the San Diego Hospice bankruptcy process in April. Van Gorder knows people who have been assisted by palliative and hospice care, and it's important to improve coordination between the two, he says.
The 24-bed San Diego Hospice plummeted into bankruptcy this year after it struggled with what Van Gorder calls the "gap in care" issue. That gap, he says, refers to the need of chronically ill patients who may not receive the care needed for their circumstances. That's what occurred at San Diego Hospice, where many of the patients who had extended stays at the hospice were diagnosed with dementia, he says.
The hospice continued to treat patients who had years left to live, not the six-month limit that CMS imposes for covering hospice costs, Van Gorder says. Of the hospice, he says, "Everybody was incredibly well-intentioned and then it went wrong. They got themselves into so much trouble. There's no question that the most important thing for them was patient care and their heart was in the right place."
While it served more patients, the San Diego Hospice failed to address CMS rules. Eventually, an audit showed that the hospice owed the federal government an estimated $60 million or more. In 2011, for instance, 475 out of San Diego Hospice's 3,700 patients—12.8%—stayed for longer than 180 days. "It's so challenging for families to take care of dementia. The hospice called itself palliative care and hospice, but they didn't have home health, they didn't have acute care," Van Gorder says. "That's why an integrated delivery system like Scripps is so well-suited to deal with these things."
By taking over the hospice, Scripps is caring for the hospice patients as part of its overall palliative and hospice care program and is planning ahead, Van Gorder says.
Scripps was among four of California's health systems whose palliative care programs were evaluated by the state's Palliative Care Quality Network. In a 24-hour evaluation of 130 patients, 46% showed reduced anxiety levels, 40% had reduced nausea, and 100% had improved dyspnea.
While the San Diego Hospice existed, the Scripps Hospital became its largest referral. Now, having the hospice brings Scripps to a level of planning a "tighter continuum of care," Van Gorder says.
Informed choices
An important component of advance care programs is patient engagement and education. Researchers have found that showing patients with advanced cancer a video decision-support tool of simulated cardiopulmonary resuscitation improved their understanding of the intervention and caused more patients to prefer to forgo CPR, say Angelo Volandes, MD, and Aretha Delight Davis, MD, cofounders of Advance Care Planning Decisions, a Massachusetts-based nonprofit that develops such videos to "empower patients with serious illnesses" to make informed choices about their end-of-life care.
Allowing patients to make informed choices is a major focus of end-of-life care, says Scripps' Van Gorder.
"We have to get our arms around it," he says. "There is that certainty: You are going to be born and die; it's going to be a sad experience but not necessarily a negative experience for the family. This is a process in which you, the patient, and the family, can go through a little more at ease than otherwise," he says.
Reprint HLR0913-2
This article appears in the September issue of HealthLeaders magazine.
MGMA-ACMPE has penned a blistering 18-page report in response to the proposed federal rule on payments to doctors, criticizing the Centers for Medicare & Medicaid Services for inaccuracy, inconsistency, and being misleading.
Big and bureaucratic, the Centers for Medicare & Medicaid Services has the last word on day-to-day healthcare policy and on physician payments. What CMS says, goes in or out of the physician paycheck.
As part of its policy-making process, CMS has closed the books on comments for its proposed rule for the 2014 Physician Fee Schedule. The CMS plan cites proposed quality measures for docs, and structures of some payment. On some level, it's part of the regulatory morass. But it carries the potential for explosive repercussions. And at least one physician organization is saying 'enough already.'
MGMA-ACMPE has penned a blistering 18-page report in response to the CMS proposed rule, criticizing the massive agency for inaccuracy, inconsistency, being burdensome, complicated, and yes, misleading.
I get the sense MGMA-ACMPE is a little fed up. "We have made a lot of these arguments, over and over," Allison Brennan, MPP, a Washington D.C.-based senior advocacy advisor for MGMA, told me. "If it seems a little tough, [it is because] we have voiced these opinions repeatedly and we continue to emphasize the importance of CMS to address these fundamental problems."
The barrage of MGMA-ACMPE complaints extends to billings, data collection, and the gathering of quality measures. Among the concerns are problems with the Physician Quality Reporting System, which is supposed to use a combination of incentive payments and payment adjustments, to report quality; and the consumer doctor rating system, Physician Compare.
Flaws in those plans and other areas of CMS policy-making are unsettling to MGMA-ACMPE and other physician groups. Among the problems, says Brennan, is that CMS is moving toward revamped regulations, even though there aren't assurances that current programs will be regulated properly.
For physicians, "there are a lot of administrative burdens, so the CMS regulations are a considerable drain on the time and resources on medical practices," Brennan says.
MGMA-ACMPE includes 22,500 members who manage and lead 13,200 organizations. Its 280,000 physician members provide more than 40% of the healthcare services delivered in the U.S, the group says. Its constituency, obviously, represents only a certain group of the estimated 1 million physicians in this country, many of whom who are represented by dozens of other organizations. But the group's outrage reflects concerns by other groups, who also have their struggles with CMS.
One such group is theAmerican Association of Medical Colleges, which includes 141 accredited medical schools, and nearly 400 major teaching hospitals and health systems.
Similarly, the AAMC has concerns over lack of standards, puzzling and confusing data questions, and contradictory elements of planning in the CMS proposals, Mary Patton Wheatley, MS, director of health care affairs for AAMC, tells me.
In its response to the physician fee schedule plan, AAMC noted that 6% of a practice's 2016 Medicaid payments are "at risk" based on reporting and performance in 2014. By having unclear objectives and standards, Wheatley says CMS is hindering physicians' chances to meet expectations. "It is essential that the Medicare program move ahead at a reasonable pace and with clear rules that are well understood," AAMC wrote to CMS administrator Marilyn Tavenner.
Yet, CMS is preparing complex changes before ensuring accuracy of existing systems, Wheatley says.
The MGMA-ACMPE and AAMC were among the dozens of physician groups who filed comments on CMS's proposed rule to revise payment policies under the physician fee schedule, for 2014. Physician groups expect CMS to issue the rules sometime in November. Whether their comments have any clout, physician groups believe they can only guess.
"I think the challenge for CMS is that they are trying to build a policy that adapts to a wide variety of specialties; multi-specialty centers, urban centers, and remote locations. And they are trying to have a single practice policy," says Wheatley. "That's why physician policies are so difficult to put together, because of the variety of physician practices, and a lot of variability."
Regardless of their constituencies, MGMA-ACMPE and AAMC are unanimous in their criticism of the CMS website used to evaluate doctors and their practices. Both groups have reported that many physicians and practices have expressed concerns about inaccurate information on Physician Compare, which they say is difficult to correct and confuses beneficiaries.
When a physician identifies inaccurate information on Physician Compare, it often takes months to be corrected, Brennan of MGMA-ACMPE says.
"We're not opposed to Medicare or CMS putting this information out there," says Brennan. "But when it's not done properly, it ends up creating more negative repercussions. Without ensuring accuracy of the information, Physician Compare is missing the mark."
In a statement to CMS, AAMC also expressed similar concerns about Physician Compare, saying it is "concerned about the validity across the different reporting mechanisms. "Finally, even with the all progress CMS has made on the Physician Compare website, group practices are still finding errors about physicians and their affiliated practices."
Neither organization has detailed exactly how many "inaccuracies" there are in Physician Compare. To improve the program, CMS has made some changes to Physician Compare, such as tweaks to a website redesign, and beefed up its information. Still, the agency's efforts have been too feeble, says Brennan, noting that it needs to conduct a "thorough analysis of the accuracy of information" on Physician Compare.
Another major problem in the fee schedule involves the Physician Quality Reporting System, which provides incentive payments to physicians.
CMS is proposing to increase significantly the required number of measures, from three to nine, that the federal agency would use to allow physicians to earn an incentive, and avoid penalties under the Physician Quality Reporting System.
Physicians groups say it's going to be tough for doctors to identify relevant measures to report their processes successfully. Many physicians and practices do not "have sufficient experience with the program to justify such a dramatic increase in the number of measures required, particularly to avoid a penalty," according to MGMA-ACMPE.
"We have significant concerns that CMS wants to increase the measures, and it essentially requires tripling the workload," Brennan says. "It's increasingly frustrating for members in the program.
It's one thing to jump hoops to earn bonus points, and then another to have to jump through hoops to avoid being penalized. That's a different story." MGMA urges CMS to finalize "more achievable criteria" for both earning a 2014 PQRS incentive and avoiding a 2016 penalty.
Indeed, CMS is moving forward before it can "ensure the accuracy and stability of the performance scoring of the cost and quality measures," the AAMC stated, adding its concerns about the proposals for the Physician Quality Reporting System.
While CMS is reviewing data and collecting information from physicians, CMS has shown no indication that it has the time to properly evaluate what it receives before it seeks new measures. Physicians have trouble keeping pace. "There is no time to make improvements, or do anything else," says Wheatley of AAMC. Once the information is collected, there are many questions wrapped around it, like, "what are the details behind it?"
Whether CMS acknowledges the physician complaints remains to be seen. Overall, however, Wheatley says, [CMS] has a very good record of trying to seek feedback."
Feedback is one thing, she acknowledges. Whatever final changes CMS makes will be the key toward potential outcomes for physician payments in 2014. "We aren't there yet," Wheatley says.
The issue of whether physician reimbursement data should be made public is creating a split among doctors. Some argue that the public has a right to know how tax dollars are being spent. Others fear payment disclosures could hurt competition.
Despite the government's stated "strong commitment to greater transparency" in healthcare, whether doctors want to publicly divulge payments they receive from Medicare is questionable. That became clear recently when the American College of Physician Executives polled its members about whether they favored public disclosure of physician payments. Peter Angood, MD, the ACPE's CEO, thought, surely, they would vote to support openness.
But when asked last month if they thought data about Medicare payments to physicians should be made public, the response is almost evenly split, with 46% of responding members saying "no" and 42% saying "yes," according to an American College of Physicians Executives poll of 508 members. An additional 12% were unsure.
The results were not exactly the 60% to 70% that Angood thought might favor transparency. "I thought it would be a little more skewed" in the direction of transparency, Angood says.
The ACPE carried out its survey in the wake of court action and Center for Medicare & Medicaid Services' inquiries around the "transparency" issue about physician pay for possible rule-making that could change decades of federal policy that kept doc moneymaking under wraps.
James C. Salwitz, MD, from New Brunswick, NJ, who is concerned about the transparency question impact, tells me bluntly: "Physicians are going to have a heart attack, they are going to run from this. You are already seeing physicians pulling out from insurance, and they have reimbursement issues, and overwhelming hassles. The first time a physician sees a patient with a printout of how much the doc made, it will be the last Medicare patient he will ever see."
The transparency issue is explosive in the physician community as some groups, including health organizations and journalists, hunger for more data about payments made to physicians. CMS concedes it is asked plenty of questions about physician payment and reimbursement data, for "research, assessment, and evaluation of programs."
Many doctors believe transparency is important, arguing that the public has a right to know how their tax dollars are being spent, according to ACPE's poll of physicians. And some doctors believe that demand from consumers will intensify. It doesn't make sense to fight it, or give in to suspicions that they may have something to hide, these doctors say.
"We live in an information age," Daniel McDevitt, MD, FACS, from Atlanta, GA, wrote to ACPE. "We should be able to look up online where our money is going at all times."
The door was kicked open on the transparency question in May, when U.S. District Court Judge Marcia Morales Howard in Jacksonville, FL vacated the longstanding injunction, handed down in 1979, that had prevented CMS from releasing information about payments to individual physicians.
Years ago, the American Medical Association, among others, successfully petitioned the court to prohibit the government from disclosing the amount of taxpayer dollars that individual doctors receive from Medicare reimbursements. The injunction was embedded for so long, HHS was known as the Department of Health, Education, and Welfare (HEW) when it began.
"Over three decades ago, this court entered an injunction that still serves as a nationwide gag order, severely limiting access to essential information about one of the most important and expensive government programs, Medicare," Dow Jones, parent company of The Wall Street Journal, wrote in court papers opposing the injunction, before Federal Judge Howard made her decision.
The injunction "is now glaringly outdated based on legal and factual landscape that there's virtually no resemblance to in the present day," Dow Jones wrote. The Wall Street Journal sought increased public access to physician records that would help expose waste and abuse, noting its limited data availability in its series, "Secrets of the System."
Prompted by the court ruling, CMS is seeking feedback to determine what specific policies it should consider with respect to disclosure of individual payment data that will further the agency's goals of improving the quality and value of care. It also seeks to determine in what form the agency should release "information about individual physician payment, should CMS choose to release it."
"In light of this recent legal development and our ongoing commitment to greater transparency in the health care system, CMS is not considering public disclosure of any information that could directly or indirectly reveal patient-identifiable information," CMS has stated.
Still, for physicians unhappy with the move toward transparency, there are questions about the process and potential data collection. "If you are talking about individual doctors and pushing out line-item payments, it's hard to imagine it will do anybody any good," says Salwitz, the New Jersey physician.
For one thing, "the data is completely unintelligible and the overhead for physician practices [varies] massively," he says. In the long run, such disclosures could hurt smaller practices because larger practitioners and healthcare corporations would have access to data that could undermine competition, Salwitz says. It could even impact physicians in their private lives, for instance, when outsiders, such as realtors evaluate their earning power, he says.
Another physician, Kenneth Maxwell, MD, from Winston Salem, NC, wrote to ACPE: "What purpose does this action serve? Publishing the amount of Medicare reimbursement without some form of normative information provides no useful information for consumers.
Despite the split among the ACPE, Angood, the group's leader, believes that the overall move toward "greater transparency in medicine and increased public reporting" is necessary and here to stay.
The differences within his group show that government regulators need to "throw up a flag of caution" as they consider all the policy changes, Angood says. "Part of our job as physician leaders is to help ensure that when health care data is presented to the public, it is accurate, fair, meaningful and useful."
Angood may have been surprised by the nearly even vote in the poll results, but not the underlying reasons why.
It reflects the "degree of the sense of disenfranchisement many physicians have," Angood says. "And when any human starts to get disenfranchised, they begin to get suspicious about what motivates the external voices changing their environment."
J.A. Mustapha, MD, works to save limbs. A big part of his challenge is persuading primary care physicians to refer patients with peripheral arterial disease to specialty services like his, where amputations may be prevented.
J.A. Mustapha, MD, FACC, FSCAI
One of J.A. Mustapha's most prized possessions is a photo of one of his patient's walking his daughter down the aisle at her wedding.
J.A. Mustapha, MD, FACC, FSCAI, saved the man's leg from amputation.
More than 100,000 adults lose limbs each year due to vascular disorders, as I report this month in HealthLeaders Media Magazine, and with an increasingly aging and heavier population at risk for diabetes, more are likely to do so.
As director of Metro Health Hospital's endovascular intervention program, Mustapha works to save limbs, and he often does. He specializes in treating patients at risk for losing limbs due to vascular disorders.
Mustapha is enthusiastic about what he does. He is grateful that he has saved many more limbs than he thought possible, at the 208-bed Metro Health Hospital in Wyoming, MI.
But some primary care doctors counseling patients whose limbs are in jeopardy don't seek out the specialty services of Mustapha or others like him, Mustapha tells me. Instead, many physicians simply examine the limbs and recommend amputation.
I found this bit of information troubling. Why would physicians not refer to him, or other specialists, if there were a chance that an amputation could be prevented? Most patients at risk of losing limbs are afflicted with peripheral arterial disease, a circulatory problem in which narrowed arteries reduce blood flow to the arms or legs.
2 Barriers to Referrals "Typically, there are two reasons a physician would not refer to an amputation prevention specialist," Mustapha says. "Lack of knowledge on the part of the referring physician about the currently available limb salvage techniques is the primary reason. The second reason is when physicians know these techniques do exist, but choose not to refer the patients for the limb salvage procedures as some would view this as a defeat on their part."
"Hence," he adds, "our push to patients and their families to be the primary advocates for saving their limbs, and their lives."
Mustapha's specialty is performing artery and vein catheterizations designed to open vessels and improve circulation. The treatment he developed at Metro uses an ultrasound-guided interventional device through the foot and an ultrasound transducer that helps identify blood flow that traditional angiography misses.
When the endovascular intervention program began five years ago, the Metro Health System saved at least 88% to 92% of limbs that had been recommended for amputation, often by the patients' primary care physicians. It now saves even more—96% to 98%, says Mustapha.
Motivated to "Never Give Up' Mustapha is touched deeply by his patients' experiences. He recalls a man in his late 50s who had visited other physicians and believed he had no other options, but an amputation. The patient desperately hoped otherwise. The man had read about Mustapha in a newspaper article, and came to see him for advice.
Indeed, the patient had been told that, "he had no options and needed an amputation," Mustapha recalls. The patient had had diabetes since childhood, but had led an active life as a teacher and sports referee. He simply wanted to keep his leg long enough to "walk his only daughter down the aisle in 6 months," says Mustapha.
Thanks to Mustapha and his team, the man was able to realize his wish. The surgeons were able to revascularize his limb, and amputation was avoided. "One of my most prized possessions is a photo of him walking his daughter down the aisle," he says. "Four years later, he is still very active and thankful for each step he has taken without pain in the past 4 years."
"It is patients like him that motivate me to never give up." [For more on what drives him, watch the video at the end of this column.]
Undertreatment Observed Non-specialist physician awareness of vascular ailments, particularly peripheral artery disease, isn't where it should be. An extensive Harvard study in 2012 showed that peripheral artery disease (PAD) remains "under diagnosed and undertreated."
While there have been many studies addressing the need for more awareness and scrutiny of vascular disease, there has been less so about preventable amputations, Mustapha says. "My sense is that the majority of physicians do not refer appropriately to an amputation prevention specialist."
One of the concerns is that podiatrists and wound care specialists treat the symptoms (wounds and foot pain) without referring for an evaluation for "potential ischemic causality, " Mustapha says, referring to the restriction of blood supply to patients' tissues.
In addition, some physicians still make the decision to recommend amputation based on "patient symptoms without obtaining a selective angiogram," a specific X-ray to determine blood flow.
But Mustapha says he holds a glimmer of hope that research and attitudes are changing, especially among primary care physicians.
"The tides are changing due to an increase in awareness, advocacy, and available data," Mustapha says. Physicians who are referring cases to specialists like him are spreading the word that amputations can be prevented.
Amputation Prevention Efforts Spreading
Amputation prevention programs such as the one at Metro Health are "a small, but growing field as this is a very important area of medicine," Mustapha says. He and his partners take every opportunity they can to improve awareness among physicians, patients and the community, he says. And Mustapha directs an annual national conference, the Amputation Prevention Symposium, devoted to critical limb ischemia.
Of those physicians whose patients later go to him on their own, and have an amputation prevented, some, but not all, are "very happy, seeking more information and increasing their referrals," Mustapha says.
Others remain obstinate, "avoiding the discussion and not changing their practice," he says.
The physicians willing to change "tend to ramp up their screening efforts and refer more patients and refer them earlier in their disease process," Mustapha says. "We always make an effort to let the patient knew their foot was saved because their current physician recognized the problem and sent them to ."
The motivation to properly care for patients "has been sapped by poorly designed incentives," one economist says. Pay-for-performance models, capitation, and bundled payments "often fall short of their goals and must be re-examined."
As healthcare organizations evaluate payment models, the role of physicians is central to where hospitals and health systems want to go and how they will improve the quality and efficiency of care.
But can providers effectively stop doctors from performing too many needless tests? Can they engage with physicians and give them proper rewards? Can patient care be improved, with a proper cost structure for all types of care and disease states? Will the move from fee-for-service to value-based care work?
Will physicians be "motivated" to achieve healthcare's goals, for population health?
"We're continuing to try to come up with some mix that is going to push the doc in this direction or that," says Francois de Brantes, an economist and executive director of the Health Care Incentives Improvement Institute. "You know the tension with docs has been, 'I'm not paid to do X, I'm paid to do Y,'' de Brantes says. "So we're moving from fee-for-service. OK, what's next? We aren't totally focused, yet people say everything is cool, and everything is going to be great."
In a recent Robert Wood Johnson Foundation report and Health Affairs blog post, de Brantes argues that as healthcare moves toward reform, it still must construct payment models that truly reflect variations of care, and incentives in provider contracts. In addition, reforms must overcome a myriad of issues ranging from innate isolation among physicians involving fiscal matters in health care systems, to dealing with improper self-referrals among physicians, he says.
Inevitably, the "carrot-and-stick" approach for physicians, whether pay-for-performance, capitation, wellness bonuses, bundled payments or consumer-directed health plans, often fall short of their goals and must be re-examined, de Brantes writes.
Poorly constructed financial models inevitably undercut physician motivation and result in undesired patient outcomes. Healthcare, inevitably, should look toward the private-sector business world to improve its efficiencies and outcomes, de Brantes says.
"Undeniably for healthcare providers, the motivation to properly care for patients and 'do no harm' significantly impacts the treatment decision-making process," de Brantes writes. "However, this motivation has been sapped by poorly designed incentives. The challenge we face in healthcare is to figure out how to reverse the incentives that currently encourage doctors, nurses, and others to make inefficient and potentially harmful health care choices."
"Said plainly, it's tough to be good when you're constantly encouraged to be bad," de Brantes says.
While Accountable Care Organizations and bundled payments and other fiscal models offer some hope for change, too often healthcare moves glacially, and can't deal quickly enough with problems, de Brantes told me.
When a healthcare academic paper is written, for instance, by the time the major focus prompts debate and change, it is often too late, de Brantes says. "We need to encourage rapid-cycle implementation where folks learn, and figure out what is appropriate," de Brantes says.
Current financial incentives to physicians "negatively affect the professional's motivation by influencing provider treatment choices and potentially harming patients who lack of easily accessible information on the value of treatments," de Brantes writes.
Among the immediate obstacles to true reform that undermines physician "motivation," de Brantes says:
Variability of Care
Health systems need to continually restructure payment models for various disease conditions and overcome variability of its funding for care, from disease to disease, specialty to specialty, subspecialty to subspecialty and region to region. As for many proposed payment models that now exist, certain modes of care, variations in oncology or cardiology, for instance, are not properly defined for proper physician payment, he says.
De Brantes also referred to expenses for treatment of various diseases or illnesses detailed in Dartmouth Atlas reports. He noted that Dartmouth Atlas found more than a two-fold difference in Medicare spending on patient care from one region of the country to another, during 20 years of studies.
The significant variations in costs of "medical episodes of care has led to well-documented waste in resources and harm to patients and oddly enough, most variability occurs with medical episodes that require the most pressing attention," de Brantes reports. To reduce variations of treatment, De Brantes says health care systems should create a "list of targets" that focus on issues such as "episode costs, price per unit, quantity and mix of services" and potential interventions.
Physician Isolation
Oddly enough, de Brantes says, while physicians are impacted by financial incentives within organizations, they are often isolated in the process.
"That's often the case for clinicians employed by large medical groups or health systems," de Brantes reports. "External payment incentives are filtered by the organization which decides how to convert those incentives into salaries and other payments for clinicians. This filtering action might have a very different impact on a clinician's motivation than the original, unfiltered incentive."
Potential Conflicts
De Brantes also lambasted some fiscal relationships involving physicians that may not only undermine their relationships with patients, but impact patient care. Physician ties to pharmaceutical, medical device or biotechnology companies that produce products they use in their practices and physician ownership of ambulatory, surgical, imaging and other freestanding facilities create potential conflicts of interest. That, de Brantes says, surely "saps" physicians' motivation, and could influence their decision-making process.
As de Brantes and I discussed his report, we talked about how hospital leadership can be involved in improving physician incentives, and push physician "motivation."
Healthcare chiefs should learn as much as they can from the private sector, particularly publicly listed corporations, de Brantes says.
"Healthcare should model itself off the private sector, [and] keep experimenting and modifying various approaches for various professionals and their organizations," de Brantes says.
His message to hospital leaders: "You should really take the CEOs, CFOs, and COOs of hospitals across the country and ship them off to Fortune 500 or Fortune 1000 companies, and shadow their counterparts in their organizations," de Brantes says. "That would be a good thing.'
"After all, let's remember that the private sector has been working on employee compensation for decades and continues to balance the incentives so that they don't get in the way of motivation," he adds.
Payments from the Medicare Primary Care Incentive Program are "a good start," to help bolster physician pay, but primary care physicians consistently fall "below 50% of the average specialty incomes," says the head of the American Academy of Family Physicians.
While primary care physicians, lagging behind other specialists in salaries, are eager to tap into the Medicare Primary Care Incentive Program's multimillion dollar bonus largess, some doctors are upset about bureaucratic "hoops and hassles" in seeking funds, says the head of the American Academy of Family Physicians.
The Center for Medicare & Medicaid Services paid $664 million to doctors, nurses, and other providers under the MPCIP in 2012, according to a recently released CMS report. Payment began in 2011 and will continue in 2015 to boost Medicare payment [PDF] for primary care services.
Referring to the millions of dollars in incentive payments, Jeffrey J. Cain, MD, the AAFP president, said in an interview that "these are good start," to help bolster primary care, especially because of projected shortages in years ahead. Still, primary care physicians consistently fall "below 50% of the average specialty incomes," Cain said.
Undoubtedly, the MPCIP is "one of the ways to incent primary care," he Cain added.
And the healthcare system is in need of primary care, he says. "We are going to have an upcoming [primary care] shortage and increasing numbers of people who will be insured; an increased aging population, and chronically ill."
Internal medicine physicians were paid 49.4% of MPCIP funds, followed by 37.9% of family physicians. Others included nurse practitioners; 7.5%; physicians' assistants 2.9%; geriatrics, 1.9%; and clinical nurse practitioners, .2%, according to CMS. The agency reported that MPCIP funds were allotted to 80% of physicians in urban areas, and 20% in rural. Incentive payments equal 10% of the Medicare paid for primary care services.
Cain did not disclose how many members of the 100,000-member AAFP have applied for the funds, but said his organization "is helping our members understand they have to be proactive" in receiving payment. "We are helping members through the process," he says.
"The number of folks who qualify (annually) is pretty stable, but we want to make sure they are part of this program. One of the things family doctors complain about is the number of hoops and hassles in Medicare and Medicaid," Cain says. The number of physicians enrolled was unavailable.
"We have to be careful as we improve payment (structures); we are not increasing the hassle factor." The AAFP is "encouraging (the government) to simplify procedures," he says.
The Medicare payment plan is authorized under the Affordable Care Act. Eligible practitioners are eligible for the payments if primary care services accounted for at least 60% of the practitioner's total allowed charges under the physician fee schedule in the qualifying calendar year. The payments are made quarterly.
To calculate a practitioner's primary care percentage, CMS states that it uses Medicare claims data from the calendar year that is two years prior to the incentive payment year. Emergency, hospital inpatient, drug and laboratory charges are excluded in the practitioner's total allowed charges under the physician fee schedule.
"This is improving fee-for service for primary care, which is great," Cain says, with a laugh, of the MPCIP. "We're pleased with that." Cain says healthcare reforms and models are necessarily being studied with the hope of aligning physician payments under value, and not fee for service.
"AAFP believes the fee-for-service system is broken," he adds. "It doesn't reflect value the services of primary care. We need to transition to a different way of paying, not just incenting (physicians) for widgets on a fee for service, volume based system, but for incent for value," Cain says.
And, he says hopefully, increased payments to primary care physicians may follow.
A California physicians organization is finding that more doctors are dismissing patients because they are uncooperative, refuse to comply with treatment, exhibit drug-seeking behaviors, and increasingly threaten the safety of care providers.
Disruptive physicians get a lot of attention. Remember the story about the surgeon who feeling, "pushed beyond my limits" slammed down an incorrectly loaded device and accidently broke a surgical technician's finger?
Last week I wrote about toxic docs, but this week, I'm turning my attention to the disruptive patient in physician practices.
Years ago, physicians would be concerned about patients who consistently were late for appointments or simply didn't show up. Then, doctors would inform patients that they would be better off seeing someone else for care.
Essentially, the patients would be "fired." Those dismissals still go on, but most of the reasons have nothing to do with the calendar or schedule. Now, most terminations involve disruptive and threatening behavior often linked to drug abuse, says Ann Whitehead, RN, JD, the vice president of Risk Management and Patient Safety at The Cooperative of American Physicians.
Doctors own CAP, a California organization that assists physicians in risk management and other services, including dealing with disruptive patients.
Doctors are dismissing patients because of "drug-seeking behavior, a request for multiple prescriptions, or a doctor identifying schedule 2 narcotics from different providers," Whitehead explains. "It's progressively getting worse, at least from looking at our call volumes. We also see more physicians being threatened than in the past."
"It has become quite important to discharge patients because they are mad for a lot of different reasons, and disruptive for a lot of different reasons," she adds. "The number of calls hasn't increased, but the reasons have totally changed. Before, patients would be discharged if they missed appointments a lot, if they came in late a lot, or disrupted the flow of the office. It wasn't efficient, because they didn't show."
Now, they are "going from one doctor to another, going down the line to get a number of prescriptions," Whitehead says.
Over a six-month period, from January 1 to June 30 this year, CAP fielded 210 calls from physicians in California, who sought advice in dealing with unwelcome patients. After a consultation with the organization, most of the physician callers took steps to fire the patients, Whitehead says. Overall, in 2012, there were 440 calls.
Sometimes the calls are alarming from worried doctors: The patient vows to come to the office to cause trouble. Their threats are credible and unsettling. CAP runs a hotline to offer specific advice to physicians about dismissing patients.
Doctors have an ethical obligation to maintain a relationship with patients once it is established, and cannot just abandon a patient. Abandonment is withdrawal from a patient without enough notice to the patient, or giving reasonable notice before care is discontinued. But certain patients are simply uncooperative, refuse to comply with treatment, and are abusive.
Some patients are tapping into the Internet and bringing in reams of documents, arguing against their care plan. Others aren't paying their bills, either. And increasingly, there are the drug issues, Whitehead says.
Under those circumstances, a physician is not required to continue treatment of these patients, but must take steps to get another physician for continuation of care, including alerting the patient about the risk of not continuing treatment, and giving the patient reasonable notice before care is discontinued.
Still, the drug issue has catapulted itself to be among the chief concerns of physicians who eventually seek to "fire" patients. While most patients seek legitimate prescriptions, others are demanding more drugs for their conditions, such as seeking pain relief. Physicians must straddle a fine line in patient care, as well as facing increasing scrutiny from law enforcement, particularly over prescriptions for opioids.
"We're sitting in the middle of a minefield," says Arnold Feldman, a pain management specialist who runs the Feldman Institute in Baton Rouge, LA.
"We have to treat in terms of ethics aligned with our oath as a professional. But we're reluctant to treat people with opioids. We won't give them to patients who look suspicious, or if they've smoked marijuana. They are banging on the door, looking for treatment."
Although, pain management physicians often have patients who are prescribed powerful drugs, they are not the doctors who most often fire patients, Whitehead says. "They are pretty well organized in their practices, and do drug testing," she says. "We are seeing more of the prescribing abuses [originating in] the general practice and specialties."
California runs databases known as Controlled Substance Utilization Reviews and Education System (CURES) and the California Prescription Drug Monitoring Program (PDMP) to help physicians monitor the drug use of patients who may visit several physician practices. "We are educating physicians to query the database when they are prescribing. If they see a large number of prescriptions out of the ordinary, they can see if their patients are getting them from other sources," Whitehead says.
While this resource is helpful, Whitehead concedes that the database isn't used by physicians as often as it should be. California's budget problems undermined the efficiency of the database at one point, she says: "That has turned some doctors off. They can't get the information they want and don't go back to it."
The potential for physical harm to physicians and other healthcare employees remains a constant concern about disruptive patients. Whether in physician practices or in the hospitals, "healthcare institutions today are confronting steadily increasing rates of crime, including violent crimes, such as assault, rape and homicide," according to a 2010 report from the Joint Commission Sentinel Alert.
"If there is acting out or threatening behavior, or if an allegation of threats is made over the phone, there is good reason to fire the patient," Whitehead says, referring to any healthcare facility. "If there are threats in person, 911 must be called."
While hospitals may have security staff, that's rarely the case for physicians. In July 2011, a psychiatrist in McLean, VA, had lunch with a friend, another psychiatrist, and expressed his concern about one of his patients, whom he said was getting paranoid and blaming all her problems on the doctor.
If that was the case, she should see someone else, his friend recalled. The doctor agreed, but the dismissal of the patient came too late: the next day he was shot dead by the 62-year-old woman, who later turned the gun on herself. That doctor didn't have a chance to fire the patient.
Second-guessing a patient's motives might not be wise, Whitehead says.
Sure, some physicians may feel a patient "didn't mean what they said, and feel I'm going to give them a second chance." That would be a mistake, she says.
"I don't think there's a second chance in this world because people carry guns."
Healthcare organizations are working to both discipline and reform physicians who display disruptive behavior. The process requires leaders to strike a tricky balance between "managing disruptive behavior" and "caring for and protecting the victims," says one expert.
A physician shoving a colleague in the operating room? A doctor yelling at a nurse, resulting in patient harm?
Two years ago, reports of those incidents were included in an American College of Physician Executives' study on disruptive physician behavior [PDF], which revealed that more than 2 out of 3 doctors witness other physicians disrupting patient care or collegial relationships at least once a month.
"Disruptive physician behavior is the issue that just won't go away," Barry Silbaugh, MD, of the ACPE said in a statement after that report was released. Indeed, it doesn't.
Indeed, disruptive behavior can be wide-ranging in its scope, ranging from verbal abuse to physical or sexual harassment, to confrontations or conflicts that cause significant fallout. When physicians are disruptive, disciplinary action may follow.
Sometimes, the situation is hopeless, and a know-it-all, bombastic physician won't try to change his attitude and outbursts. In those cases, the doctor has to be dismissed. But other physicians who act in a disruptive way may recognize trouble with their own behavior, have a desire to improve, and make a commitment to work vigorously for change.
That's why it is important to examine the root causes of disruptive behavior, understand the culture of medicine, and develop programs that could rehabilitate physicians from an organizational and individual perspective, says Hardley Paolini, PhD, LP, a licensed psychologist and director for Physician Support Services at Florida Hospital in Orlando.
Hospitals straddle the line in determining which physicians must be ousted after failing to respond to disciplinary action, and identifying those who can be rehabilitated. Making inroads in this improvement process can be a sensitive balancing act.
Too often, Paolini says, healthcare has not kept up to the challenge of disruptive physicians. "We have not trained our physicians for the resiliency they need, for the teamwork they need right now. When you see 40 to 60% of burned-out physicians, you are going to see some of these behaviors come out not only in depression, but also in aggression," she says.
It's important for hospitals and physician groups to address disruptive behavior when it first appears, by not making excuses for "high performers and politically protected employees who harm others," says William "Marty" Martin, PsD, MS, MPH, PsyD, CHES, director and associate professor at DePaul University in Chicago and a former member of the American College of Physician Executives faculty.
Healthcare organizations must deal with the issues incrementally, from the first "cup of coffee," trying to understand the issue when discussing it with a physician, Martin says. If the issue recurs, a peer review may be needed, and possibly followed by disciplinary action.
"You have to make it a bit more formal. You have to put on your risk management hat because you don't want to railroad that particular physician, but you do want to balance what's good for the organization and what's good for the individual. "That includes, of course, discussions with someone who may have filed a complaint.
Hospitals must strike the balance of "managing disruptive behavior" and "caring for and protecting the victims," he says. At Florida Hospital, physicians who engage in disruptive behavior have a chance to retain their positions, depending on the circumstances.
Over the last decade, the hospital has intervened with at least 1,000 physicians and their family members. At least 100 physicians who may have lost their positions were able to keep their jobs because of the hospital's intervention services, Paolini says.
Those services include counseling, psychotherapy, wellness programs, and a safe harbor reporting system. Among their techniques is having counseling staff "embedded" with the physicians, coaching them toward improvements in relationships with other staffers. "We rub shoulders with them, "she says. "We have a comprehensive approach."
The hospital also conducts retreats for the doctors. "We take them out of town and address the whole burnout issue. We examine where the gaps are. We've been very proactive about it," says Paolini, who is also author of a book on the issue.
The hospital has been successful in helping physicians. But not everyone. For some of those, "if it's broken, it can't be fixed. And when that happens, you know," Paolini says.
Next week, this column will examine the issue of disruptive patients.
Cardio care is a growing margin contributor for hospitals and health systems. That's why healthcare providers are retooling in a big way to develop cardiac care subspecialty programs.
This article appears in the July/August issue of HealthLeaders magazine.
With cardiology among the fastest growing service lines, hospitals are retooling in a big way to win market share by developing cardiac care subspecialty programs that will give them a competitive edge in a flourishing market.
Already, cardio care is a significant and growing margin contributor for hospitals and health systems, with 76% reporting positive margins for cardio and 66% expecting this service line margin to increase over the next three years, according to the March HealthLeaders Media Intelligence Report, Reshaping the Cardio Service Line for Population Health and Reform Challenges. Yet hospitals believe they must tweak their existing programs to create differentiators that will lure more patients in need of greater specialization of care.
Creating multidisciplinary teams with advanced specialties is an important component of wide-ranging heart programs that reach a broad patient population. Faced with more elderly patients who have chronic conditions, hospitals are initiating changes to provide specialized care that will save patients, using what David Wohns, MD, medical director of the cardiac cath labs and interventional cardiology program for Spectrum Health System in Grand Rapids, Mich., calls "a bridge to recovery." Spectrum Health has nine hospitals, 130 ambulatory and service sites, and 1,938 licensed beds.
"There are new technologies, pumps and assistive devices that can be applied percutaneously or surgically placed. Because of percutaneous procedures, we are able to save people who are very sick, and five years ago they couldn't survive," says Wohns. "It may be a percutaneous device placed in the cath lab or surgically placed in the operating room as that bridge to recovery."
Spectrum has developed a broad swath of programs to improve care, ranging from the development of a transplantation program and ventricular assist device program to a multidisciplinary shock team for critically ill patients.
As a result, surgery volumes at the hospital's Frederik Meijer Heart & Vascular Institute have far exceeded the average for hospitals that are members of the Society of Thoracic Surgery. In 2012, Meijer's bypass surgery volume reached 411, compared to 155 for the average STS member. It handled 444 valve surgeries, compared to 67 for STS.
Within the hospital system itself, Spectrum has greatly increased patient volumes in subspecialties. Its ventricle assist device implant volumes increased from four in 2009 to 48 in 2012, and its heart transplants increased from two in 2010 to 20 in 2012. In the meantime, its heart failure readmissions—at 23% in 2012—were favorable compared to the national average of 24.8%, based on Medicare data about patients discharged between July 1, 2007, and June 30, 2012.
Hospitals are seeking better market share in cardio specialties and subspecialties to improve care and realize increased ROI. New endovascular procedures are emerging as patients want the benefits of reduced trauma compared to open procedures and the faster recovery associated with minimally invasive surgery and interventional procedures.
Cardio specialties are related to general heart care and vascular surgery, while subspecialties refer to specific cardiac programs, including internal and critical care medicine, interventional cardiology, pulmonary disease, heart failure, cardiovascular disease, transplants, adult congenital heart disease, and others. The American Board of Medical Specialties certifies specialties and subspecialties.
The 437-licensed-bed University of Colorado Hospital in Aurora is expanding programs for congenital heart disease, finding an increased need for specialization. UCH also is among a growing number of organizations working to increase patient volumes by developing advanced subspecialty programs. It offers fenestrated endograft stents as new treatment options for abdominal aortic aneurysms, providing a service for patients who would not otherwise be candidates for traditional endovascular repairs.
The procedures have resulted in decreased complications, early discharge, and a quick return to normal quality of life, says David Kuwayama, MD, MPA, a vascular surgeon and assistant professor of vascular surgery.
"Over time, we've seen an increasing patient load and a lot more referrals for complicated aneurysm disease. There is clearly significant patient demand for minimally invasive ways to treat these problems," says Kuwayama.
More hospitals are also performing cardiac catheterizations through the radial artery, which has proven to lower the risk of vascular complications. Only about 8% of cardiac catheterizations are performed using the radial approach, but hospitals say they realize the patient benefits of transradial interventions.
The 547-licensed-bed Ochsner Medical Center in New Orleans is focusing on such cardio repairs to capture a patient market, says J. Stephen Jenkins, MD, FACC, FSCAI, associate section head for interventional cardiology and director of the cardiac catheterization laboratory. "Everything is going to minimally invasive techniques," says Jenkins. "We repair aneurysms in a minimally invasive way that 10 or 15 years ago was done surgically."
Although some hospitals are moving tentatively with subspecialties, Spectrum's Wohns says "I don't think these are a passing fad because there is increased data on reduced cost and increased patient satisfaction, increased safety and fewer adverse events. I think the trends will continue as the story unfolds, with economic benefits, too."
Spectrum and other hospitals are investing millions of dollars in hybrid ORs, which are considered an ideal setting for minimally invasive procedures that require advanced imaging. Some hospitals are using the hybrid OR to pursue innovative cardio subspecialty procedures to treat patients who are too ill to undergo traditional surgery.
One notable procedure is the transcatheter aortic valve replacement, or TAVR, says Zoltan Turi, MD, FACC, FSCAI, director of the structural heart disease program at the 493-bed Cooper University Hospital in Camden, N.J.
"Because we have access to TAVR, we have become a referral site for cardiologists who have patients they are reluctant to send to hospitals for surgery," Turi says. "The number of hospitals that use TAVR is growing. When we started, we were one of the first ones. Now there are more than 200 sites in the U.S."
The hybrid OR opens the door for such procedures.
The 442-staffed-bed St. Peter's Hospital in Albany, N.Y., is also high on hybrid ORs to improve outcomes and offer variety in cardiac care.
"We do a tremendous number of endovascular procedures and have great outcomes. The robotic equipment allows us to visualize the reconstruction of the aorta through a synchronized imaging display," says Dorothy Urschel, MS, ACNP-BC, RNFA, NEA-BC, MBA, the cardiac and vascular service line director for St. Peter's Health Partners. Urschel says the hybrid ORs have enabled minimally invasive surgeries that typically require shorter lengths of stay and faster recovery than open procedures. "Many surgeries are going to be minimally invasive."
Over the years, hospitals have been buying more and more hybrid OR suites, with a 10% growth each year over the past two years, according to the ECRI Institute, a nonprofit organization based in in Plymouth Meeting, Pa., that researches healthcare cost-effectiveness.
There is growing market pressure on hospitals to have hybrid ORs, says Thomas Skorup, FACHE, vice president for applied solutions at ECRI, as more physicians want to perform new combinations of endovascular laparoscopic surgery or open procedures in the same OR with advanced angiography image guidance. Hybrid OR suites comprise up to 100 different medical devices and systems from multiple vendors, with key technologies such as a fixed angiographic imaging system.
One of the major issues is cost. Hospitals leaders considering hybrid ORs must evaluate how they plan to use each 900- to 1,400-square-foot system in the surgical theater, and should expect hefty expenses involved, ranging from $3 million to $4 million for each suite. Because of the expense, the possibility for short-term ROI is questionable. Staff training and development are essential for the safety and efficiency of the hybrid OR, which is double the size of a standard OR, Skorup says.
Hospitals need to evaluate purchasing, pricing, and the right imaging system to meet the different needs of their organizations, Skorup says.
"I've seen institutions making great investments in technology like the hybrid OR or cath lab or interoperative MRI," he says. There are some instances, however, where hospitals are saying, 'We aren't using them as much as we would have expected,' " Skorup says.
Success key No. 1: Amputation prevention programs
Every year, more than 100,000 adults lose limbs due to vascular disorders, and with an aging and increasingly heavier population at risk for diabetes, more are likely to do so. Most patients at risk of losing limbs are afflicted with peripheral arterial disease, a circulatory problem in which narrowed arteries reduce blood flow to the arms or legs.
The vascular amputation program at 208-bed Metro Health Hospital in Wyoming, Mich., has focused on improving circulatory care for patients and preventing amputations, even though some recommendations for amputation originated with patients' primary care physicians.
J.A. Mustapha, MD, director of Metro Health's endovascular intervention, heads the hospital's vascular amputation prevention program. His specialty is performing artery and vein catheterizations designed to open vessels and improve circulation. In the process, the hospital has developed a technique to treat vascular systems successfully and in many cases avoid amputations. The treatment approach uses an ultrasound-guided interventional device through the foot and an ultrasound transducer that helps identify blood flow that traditional angiography misses. Often, medication can address this condition to prevent amputations.
When the endovascular intervention program began five years ago, the Metro Health System saved at least 88% to 92% of limbs that had been recommended for amputation. It now saves even more—96% to 98%, says Mustapha. Limb preservation care is part of Metro Health's overall work in peripheral arterial disease, an area in which patient volumes have increased dramatically at the hospital. Over the past five years, the volume of cases has increased from 67 to 827, he says.
"We are asking for more operating rooms and staff, and we are booked," he says. "We are improving care and making money for the hospital."
The hospital uses a diagnostic technique that "basically goes down around the foot area and puts a small catheter in there to take pictures. We mastered the method of clearing the vessels, have a plan of attack to follow and we stick with it," says Mustapha, adding that "it's amazing we are saving 96% of the limbs; we would have been happy saving 50%."
Physicians have referred cases to the hospital after they believed there was no other option than amputation, Mustapha says. Too often, these doctors lack superior techniques to properly evaluate areas of the leg or feet that may be impacted, he explains.
At Metro's amputation prevention program, all referred patients scheduled for amputation are seen within 24 hours. If there is no contraindication, patients will then undergo peripheral angiography within 48 hours.
Primary care physicians often rely on "conventional angiograms that do not detect blood flow below the knee," Mustapha explains. As a result, "these physicians see a brick wall and believe there is nothing else to do [other than amputation]." Some physicians make a singular decision and do not make referrals for second opinions and amputations are performed. "It's a sad thing," Mustapha says.
An important key to building a successful peripheral vascular disease program is partnering with and educating the referring physicians, who include primary care providers and podiatrists, Mustapha says. Hospital peripheral interventionists visit physician offices in the field to educate primary care doctors on peripheral vascular disease screening.
Metro Health's PVD program includes collaborations with other specialists, including those involved in interventional radiology, cardiology, vascular surgery, and wound healing. Patients are instructed about healthful practices, including the need to quit smoking, follow a reasonable diet, and exercise.
The hospital's program began after Mustapha counseled a 52-year-old patient with severe PAD in her leg. Mustapha made the connection that a device commonly used to clear clogged arteries leading to the heart could be adapted for PAD. "It opened the door to what we are doing. This created a cascade of events that have been successful beyond what we thought possible," Mustapha says. "Patients are so grateful when we are saving a limb. Ironically, when we save their lives, they aren't as expressive."
Success key No. 2: Congenital heart disease
For years, children were the primary focus of congenital heart care. But many youth afflicted with congenital heart disease are now living past 18 years, which translates into an increased need for treating them as adult patients. However, only 10% are seeking appropriate care from adult congenital cardiologists, according to the Adult Congenital Heart Association. More than 1 million adults in the United States live with congenital heart disease.
"Probably the majority of these adult congenital patients who are seeking cardiology care are in pediatric care still," says Joseph Kay, MD, program director of the University of Colorado Hospital adult congenital heart disease program. "So a pediatric cardiologist who followed them throughout their lives is still managing them, through adulthood in the U.S. But it's not the ideal scenario."
UCH is finding a niche market by improving care for adults and children, says Kay.
Unlike many hospitals, UCH has both a pediatric program and an adult program for former pediatric patients. Kay, for instance, is qualified in both adult and pediatric care. There are now 1,200 people enrolled in the UCH program, which has added 200 patients a year over the past several years, he says. "We're almost at capacity, for the number, in our facility."
It's important to have an effective adult congenital multidisciplinary team to treat older patients, Kay says. In many instances, pediatric physicians are continuing to treat older patients into adulthood, but there are gaps in care, he says.
Congenital defects occur in about 1 in 120 births, according to the ACHA. Surgical repairs and other interventions are allowing babies born with serious congenital heart defects to live into adulthood. "The survival rate for children has gone up exponentially," about 95% to 98%, Kay says. "Children who never survived into adulthood a decade ago are now surviving in large numbers."
At least 75% to 80% of patients with congenital problems are not cared for in adult congenital heart centers, he adds. "Many of the [adults] are not receiving care at all. Many of them have the false impression that they were fixed as children. We believe there is an absolute need for practitioners in the field, and the field is going to continue to grow."
There is also is a growing need for follow-up care in an adult congenital heart subspecialty, Kay says. Survivors have a greater risk than other people of developing additional heart problems because of changing blood flow patterns in the heart. Long-term problems include rhythm disturbances, valve problems, heart failure, endocarditis and stroke.
Adult patients require the skills of a clinical team with experience in adult comorbidities, such as diabetes or hypertension, and can offer guidance about employment, pregnancy, and physical activity, Kay says. Adult patients who seek care in adult congenital heart centers report fatigue, exercise intolerance, chest pain, shortness of breath, or palpitations.
"Many adult congenital programs hadn't existed until the past few years," Kay says. "So many adult cardiology specialists had little or no exposure to patients and lacked the experience in understanding how to give them true optimal care." In December, the American Board of Medical Specialties created a physician certification in adult congenital heart disease as a subspecialty, which may increase the number of cardiologists who gain an expertise in that area, Kay says.
Success key No. 3: Atrial fib
Atrial fibrillation is a serious heart rhythm abnormality seen by physicians. It is marked by a rapid, irregular heartbeat originating in the small, upper chambers of the heart. If not treated effectively, it can lead to stroke, serious bleeding, cardiac arrest, and death.
Most people with atrial fibrillation have identifiable risk factors, such as high blood pressure or structural heart disease, and tend to be over age 60. About 6 million American adults have been diagnosed with atrial fibrillation or an irregular heartbeat. "It's not going away and it's on the rise," says Andre Gauri, MD, electrophysiologist with the Spectrum Health's heart and vascular program.
At Spectrum Health, over the years, many patients have been admitted for afib observation. As the country moves toward value-based care, this practice has been questioned, and Spectrum is one of many hospitals that realized its protocol of hospitalization for observation was unnecessary, Gauri explains.
As a result, Spectrum developed a dedicated atrial fibrillation clinic to improve evaluation of afib and improve care, Gauri says. The clinic team includes five board-certified electrophysiologists, six electrophysiology RN case managers, and two electrophysiology midlevel providers.
Spectrum realized that, until recently, "we were admitting patients essentially to do an outpatient workup half the time," Gauri says. "All these patients would get admitted to the hospital, get a whole bunch of tests, go home, and then follow up as an outpatient."
Instead, "if a 45-year-old patient with no prior history of severe cardio problems develops a rapid heartbeat, she can be put in the observational unit and then followed in the afib clinic within 48 hours, and other tests are done," Gauri says.
By utilizing the clinic, Spectrum has increased its volume of procedures, including afib ablations, which increased from 270 in 2009 to 400 in 2011. Ablation is a procedure used to treat arrhythmias. The type of arrhythmia determines how ablation would be performed. Evaluations of supraventricular tachycardia, a common heart rhythm disturbance where the heart beats faster than it should, increased from 500 in 2009 to 550 in 2011. At Spectrum, other evaluations—such as premature ventricular contractions, a cause of irregular heart rhythms—increased from 25 to 50 from 2009 to 2011.
Patients are seen and evaluated within three days of referral. The clinic also provides a timely response for monitoring mediation therapy and devices.
"There's a large variety of ways to treat afib," says Gauri. "At least 15% to 20% of procedures can be medically stabilized in a 24-hour observational unit, and that won't count for hospital admissions. In the beginning, there was some pushback about the unit, but now physicians are seeing the value."
Success key No. 4: TAVR program
Although open-heart surgery, also known as surgical aortic valve replacement, has been considered the standard for replacing aortic valves for severe aortic stenosis, some elderly and frail patients with varied complications are physically unable to withstand the procedure.
As a result, more hospitals are trying to fill that gap by providing transcatheter aortic valve replacement, or TAVR, as alternative treatment for aortic stenosis, says Turi, director of the Cooper University Hospital center.
Aortic stenosis and aortic valve disease affects nearly 300,000 Americans, and that is expected to increase significantly over the years, Turi says. "As the population ages, aortic stenosis is going to be more and more prevalent and it will be more of a problem for healthcare," Turi says. With aortic stenosis, "there's wear and tear on the heart valve, like pitchers' arms," he says. "The valve is full of calcium and it creaks open rather than flies open."
With conventional aortic valve replacement, surgeons make an incision in the chest, stop the heart, put the patient on a heart-lung bypass machine, and remove the old valve replacing it with a new one. They then restart the heart and sew up the chest.
With TAVR, the new valve is placed inside the old valve while the heart is still beating and deployed with the aid of a balloon that pushes aside the old valve and allows the new valve to expand into place. The valve is introduced through a puncture in an artery in the leg or through a small incision made in the side of the chest.
People who have symptomatic aortic stenosis have a mortality rate as high as 50% in one year. With TAVR, people who have had previous chest or heart surgeries, severe lung disease, chest radiation, or other serious medical conditions have another chance to live better and longer lives, Turi says.
With TAVR, Turi says, "There's a less invasive procedure and patients tolerate it better. It's much easier on the patient."
Cooper University Hospital is now involved in clinical trials named PARTNER (Placement of Aortic Transcatheter Valve), which evaluated TAVR. According to the findings of PARTNER studies in 2011 and 2012, there was comparable or even favorable quality and efficiencies for the procedure compared to open surgery. In a study known as PARTNER B, survival for patients at one year was significantly higher with TAVR (69.3%) compared to patients who received other therapy (49.3%). The trial included 380 patients in 21 hospitals and academic facilities in the United States, Canada, and Germany.
TAVR patients also had fewer hospitalizations and better symptom relief than did those receiving standard medical care. The University of Colorado Hospital also participated in the PARTNER trials, says John Carroll, MD, director of cardiac interventions at the UCH. TAVR is among the "novel therapies [that] are really transforming [cardiovascular care]," he says.
Implementing TAVR in hybrid ORs requires a special team approach, says Turi. "Sites that have succeeded need a strong working relationship among multiple disciplines," he says."
Like the hybrid OR, the solutions hospitals pursue for cardiology subspecialties are apt to be hybrid—known for their adaptability, efficiency, and efficacy in care as the population of patients needing this kind of treatment soars.
Reprint HLR070813-7
This article appears in the July/August issue of HealthLeaders magazine.
Doctors groups are alerting members to be prepared to respond to public disclosures as pharmaceutical and medical device manufacturers begin tracking and reporting their financial interactions with physicians.
Ardis Dee Hoven, MD
The American Medical Association and other physician groups have scrambled to alert doctors to prepare to respond to what may be some embarrassing disclosures.
Under the Physician Payment Sunshine Act, which went into effect Thursday, drug and medical device manufacturers are required to begin tracking and reporting financial interactions with physicians. The law requires public reporting of payments to physicians and teaching hospitals.
This means that honoraria, gifts, and other "transfers of value" physicians receive from pharmaceutical and medical device manufacturers will be reported. Manufacturers are required to collect and report this data to the Centers for Medicare & Medicaid Services, which will publish it in an online database by Sept. 30, 2014.
Physician groups acknowledge that many doctors aren't up to date on the requirement, which is designed to perpetuate "transparency" in a field sometimes clouded by complicated relationships and payments involving physicians and pharmaceutical companies and device manufacturers.
"We strongly urge physicians to make sure all of their financial and conflict of interest disclosures, as well as their information in the national provider identifier (NPI) database, are current and regularly updated," AMA president Ardis Dee Hoven said in a statement.
Over the years, several investigations that have focused on doctors being paid by drug companies whose medicines they prescribe, or for having alleged conflicts with medical device manufacturers who make implants the doctors use.
Last fall, a Senate Finance Committee investigationrevealed what it termed "questionable fees between the Medtronic medical device company and the physician consultants tasked with testing and reviewing Medtronic products. In 2011, a Pro Publica investigation showed that the same drug companies whose medicine they prescribe are paying many doctors.
"(Thursday) is an important day, but not the most important day," says Jonathon Kellerman, principal in PwC's Pharmaceuticals and Life Sciences Industry Group. "It marks when manufacturers must start collecting data. It is an internal challenge. The clock really starts ticking when the first reporting period begins."
Pharmaceutical and device manufacturers are slated to turn over their first reports to CMS on March 31, 2014. Physicians will have a minimum of 45 days to challenge any information before it is public and they may dispute inaccurate reports and seek corrections during a two-year period.
Physicians may also ask manufacturers and their representatives to provide information they intend to report. Doctors may register with CMS, beginning in January 2014, to receive a consolidated report on activities each June for the prior reporting year.
The Sunshine Act covers gifts or payments valued at $10 or more. The only physicians exempt are medical residents because many do not have a National Provider Identifier or a state professional license.
Ray Quintero, director of government relations department at the American Osteopathic Association in Washington D.C., acknowledges that the information the government receives is "reliant on the pharmacy or device manufacturer. What we are trying to do is prepare our physicians, and ensure that the information is reviewed for accuracy. If something is inaccurate, it should be disputed."
"This is the first time a federal standard has been created around data reporting, and payment," related to pharmaceutical companies and device manufacturers, says PwC's Kellerman. While many companies have prepared for the disclosures, there are significant challenges ahead, he adds.
One hurdle may involve third-party vendors, and the lack of standardization of data "across multiple systems," according to Kellerman. "It's incumbent upon healthcare professionals to keep their eyes and ears open about registration and guidelines and to review the data so they can take ownership of the information that is being published," he says.
According to a 2007 study the New England Journal of Medicine, 94% of physicians had a relationship with the industry; 83% received gifts, and 28% received payments for professional services, such as consulting or research participation.
Prior efforts to increase disclosure of industry-physicians financial relationship include a 2009 Institute of Medicine report, that developed recommendations "to identify, limit and manage without affecting constructive collaborations with industry and called for broad public transparency," according to the NEJE report.
The Physician Payment Sunshine Act was created by Congress to ensure transparency in physicians' interactions with the pharmaceutical, biologic and medical device industries as well as group purchasing organizations.
The law covers meals, honoraria, travel expenses, and grants from manufacturers, and ownership and investment interests by physicians or members of their immediate family. Eventually, physicians who have received payments or hold ownership will be posted on a website, under the National Physician Payment Transparency Program of the CMS.