Maybe hospital executives have too much on their plates already. There may be too many pressing issues to contemplate – such as understanding the impact of the dizzyingly complicated healthcare reforms, installing electronic medical records, or even keeping the doors open and the lights on.
Whatever the reason, the 2011 HealthLeaders Media Industry Survey found that over the past year, recruiting and retaining physicians dropped from the No. 2 “top priority” to No. 7. Did something happen in the last 12 months that relieved the nation’s chronic physician shortage? Did the U.S. demographic get younger, slimmer, more physically fit?
Well, no; the need for physicians is as strong as ever, but the need to focus on recruitment and retention has softened somewhat. The top priorities that ranked above physician recruiting and retention in 2011 are, in order, cost reduction, quality/patient safety, reimbursement, patient experience/patient satisfaction, developing an accountable care organization, and care coordination.
Despite the shifting priorities, hospital leaders do not appear to be in denial about the physician shortage. Only 29% are positive about the supply of primary and specialty care physicians over the next three years, while about 40% see supply as having a negative impact. And yet, 67% of hospital leaders rank their current physician staff as “strong” or “very strong,” which is down from 78% last year. Meanwhile, 9% of leaders describe their physician staff as “weak” or “very weak,” not much better than last year’s 10%.
So leaders need to decide as they walk past every 10th physician, should physician recruitment—with an eye on quality—be a higher priority?
The College of Healthcare Information Management Executives (CHIME) has recommended that the federal government push back the deadline for Stage 2 implementation of meaningful use until the impact of Stage 1 on hospitals can be more accurately evaluated.
"Absent such as assessment, we greatly fear that the (Health Information Technology Policy Committee's) proposals for Stage 2 may be unduly ambitious, even unattainable, for many eligible hospitals and eligible professionals," CHIME President/CEO Richard A. Correll and Lynn Vogel, MD, chair of the CHIME board, said in the Feb. 18 letter to Joshua Seidman at Health and Human Services' Office of the National Coordinator for Health Information Technology.
The CHIME leaders said that seeking public comment about Stage 2 implementation before a proper assessment of Stage 1 "is a big like putting the cart before the horse."
CHIME recommended not moving to Stage 2 until about 30% of eligible hospitals and providers have been able to demonstrate competency with stage 1 meaningful use.
"We believe this approach would strike a reasonable balance between the desire to push EHR adoption and MU as quickly as possible and the recognition that unreasonable expectations could end up discouraging EHR adoption if providers conclude that it will be essentially impossible for them to qualify for incentives," CHIME wrote.
CHIME also suggested that Medicare allow hospitals and providers to "skip a year" if they are not fully prepared to move to the next stage. "CHIME sees no value to imposing some artificial deadline on the movement to stage 2 and urges ONC and CMS to take all the time needed to produce clear and understandable policies. We consider this better than rushing the rulemaking process only to have to repeatedly issue frequently asked questions (and answers) and other policy clarifications and explanations to address provider and EHR vendor confusion and uncertainty," CHIME said in the letter.
The average per capita cost of healthcare services covered by commercial health plans and Medicare programs rose 6.06% in 2010, matching the lowest growth rates in four years, and continuing seven consecutive months of cost growth deceleration, according to the Standard & Poor's Healthcare Economic Indices.
A further S&P breakdown shows that – even with its older, sicker population and higher utilization, Medicare’s growth in per capita costs – at 3.27% in 2010 – was less than half the rate of cost growth for commercial plans, which saw an increase of 7.75% for the year.
David M. Blitzer, chairman of the Index Committee at Standard & Poor’s, said the slower rate of growth in Medicare, doesn’t necessarily mean the federal government does a better job delivering healthcare. “The federal government does a better job than the private sector of legislating prices,” Blitzer said. “It’s a combination of the Medicare fee caps that are set by the government, even after they’re moderated from time to time by Congress. And, almost inevitably, there is cost shifting. I don’t think that Medicare is necessarily doing a better job of cost containment, but they are doing a different job of writing down the price list.”
The S&P monthly estimate for the 12-month period ending in December showed that medical inflation slowed 0.21% when compared with the 6.27% growth reported for the 12-month period ending in November 2010. The rate of growth has fallen 2.68 percentage points since May 2010, Blitzer says.
“The December year-end report shows that the trend of slowing annual growth rates in healthcarecosts that started in early/mid-2010 continued through the end of 2010,” Blitzer says. “The Composite Index posted a new recent low in the annual growth rate (+6.06% in December), a level last seen nearly four years ago during the summer of 2007.”
Healthcare cost increases continue well above the rate of inflation in the larger economy, which grew 1.6% for the 12-month period ending in December as measured by the Consumer Price Index. Most of that growth was fueled by rising food and energy costs, the Bureau of Labor Statistics reports.
Blitzer says some of the reduced rate of growth in healthcare costs may be attributed to the recession and the slow recovery. “What we are seeing and what we are still benefitting from is that until very recently general inflation in the economy was slowing down,” he says. “Looking at trend over the last 12 months we are still benefitting of what has been a deceleration in inflation that goes back to the beginning of the financial crisis. We may also be seeing some moderation in terms of employment trends. Less growth in employment in physicians’ offices and hospitals will slow down expenditure numbers too.”
Whatever the reason, Blitzer says the new healthcare reforms are not a factor. “There is nothing we are seeing that we can either credit or blame on the healthcare reforms. It’s too early in the process,” he says. “While I’m sure one side would love to say costs are rising more slowly because of healthcare reform and the other side would like to say healthcare reform is going to ruin us, we can’t answer that question either way.”
The December S&P indices found that:
Claim costs associated with hospital and professional services for patients covered under commercial health plans rose 7.75% over the year ending in December, down from 7.79% for the year ending in November, and 8.19% for the year ending in October, but well above the historical low of +6% annual growth rate posted in September 2005.
Medicare claim costs for the same services rose 3.27% over the year ending in December -- the lowest annual growth rate for Medicare claims in the six-year history of the S&P indices. In the year ending November 2010, Medicare claims costs rose 3.74%.
The S&P indices estimate the per capita change in revenues accrued each month by hospital and professional services facilities for services provided to patients covered under traditional Medicare and commercial health insurance programs. The annual growth rates are determined by calculating a percent change of the 12-month moving averages of the monthly index levels versus the same month of the prior year.
“The year 2010 was highlighted by a trend of deceleration in annual growth rates for all three headline indices – the Composite, the Medicare and the Commercial Indices. Especially since May 2010, most of the indices annual growth rates have declined month-to-month,” Blitzer says. “The S&P Healthcare Economic Hospital and Professional Services Indices also show a similar moderation in the rate of increase of annual growth rates, posting +5.60% and +6.34% rates for December 2010, respectively, versus May 2010 prints of +7.99% and +9.33%, respectively.”
At least eight physicians, eight nurses, four physical therapists, and several healthcare company owners and executives were among the 111 people in nine cities who were charged Thursday in separate Medicare fraud investigations that federal investigators say were responsible for at least $225 million in false billings.
More than 700 law enforcement officials executed 16 search warrants in the round ups – the largest one-day sweep of its kind. Led by the federal Medicare Fraud Strike Force, law enforcement officials made arrests in Miami, Brooklyn, Houston, Los Angeles, Baton Rouge, Tampa, Detroit, Dallas, and Chicago, the Department of Justice and Health and Human Services said in a joint announcement.
"With this takedown, we have identified and shut down large-scale fraud schemes operating throughout the country, we have safeguarded precious taxpayer dollars, and we have helped to protect our nation's most essential healthcare programs, Medicare and Medicaid," Attorney General Eric Holder said at a news conference Thursday afternoon announcing the sweep.
Also Thursday, DOJ and HHS announced the expansion of the Medicare Fraud Strike Force to Dallas and Chicago.
"Over the last two years our joint efforts have more than quadrupled the number of anti-fraud Strike Force teams operating in fraud hot spots around the country from two to nine -- with the latest additions Chicago and Dallas -- bringing hundreds of charges against criminals who had billed Medicare for hundreds of millions of dollars," HHS Secretary Kathleen Sebelius said. "Last year alone, our partnership recovered a record $4 billion on behalf of taxpayers. From 2008-2010, every dollar the Federal Government spent under its Health Care Fraud and Abuse Control programs averaged a return on investment of $6.80."
The 111 people charged on Thursday are accused of various healthcare fraud-related crimes, including conspiracy to defraud Medicare, criminal false claims, violations of the anti-kickback statutes, money laundering and aggravated identity theft. The charges are based on alleged fraud schemes involving various medical treatments and services such as home health care, physical and occupational therapy, nerve conduction tests and durable medical equipment.
Prosecutors said the defendants participated in schemes to submit claims to Medicare for treatments that were medically unnecessary and often never provided. Indictments and complaints allege that patient recruiters, Medicare beneficiaries and other co-conspirators were paid cash kickbacks to supply beneficiary information to providers, so that the providers could submit fraudulent billing to Medicare. Collectively, the doctors, nurses, healthcare company owners, executives and others are accused of submitting more than $225 million in fraudulent billing, DOJ said.
·In Miami, 32 defendants, including two doctors and eight nurses, were charged in various fraud schemes involving a total of $55 million in false billings for home health care, durable medical equipment and prescription drugs.
·In Detroit, 21 defendants, including three doctors, three physical therapists and one occupational therapist, were charged in schemes to defraud Medicare of more than $23 million, in cases involving false claims for home health care, nerve conduction tests, psychotherapy, physical therapy and podiatry.
·In Brooklyn, NY, 10 people, including three doctors and one physical therapist, were charged with fraud schemes involving $90 million in false billings for physical therapy, proctology services and nerve conduction tests.
·In Tampa, 10 people were charged in connection with schemes involving more than $5 million related to false claims for physical therapy, durable medical equipment and pharmaceuticals.
·In Houston, nine people were charged in schemes involving $8 million in fraudulent Medicare claims for physical therapy, durable medical equipment, home health care and chiropractor services.
·In Dallas, seven people were indicted for conspiring to submit $2.8 million in false billing to Medicare related to durable medical equipment and home healthcare.
·In Los Angeles, five people were charged in schemes to defraud Medicare of more than $28 million, involving false claims for durable medical equipment and home health care.
·In Baton Rouge, six people were charged for a durable medical equipment fraud scheme involving more than $9 million in false claims.
·In Chicago, charges were filed against 11 people in businesses that have billed Medicare more than $6 million for home health, diagnostic testing and prescription drugs.
Since their inception in March 2007, Strike Force operations in nine districts have charged more than 990 people who collectively have falsely billed Medicare for more than $2.3 billion.
Six states and a consortium of New England states will split $241 million in federal “Early Innovator” grants for developing health insurance exchanges for small businesses and individuals that could serve as national models when the programs launch in 2014, the Department of Health and Human Services announced Thursday.
“Early Innovator states will play a critical role in developing a consumer-friendly marketplace where insurers must compete to deliver the best deal,” said HHS Secretary Kathleen Sebelius. “These grants ensure that consumers in every state will be able to easily navigate their way through health insurance options.”
Starting in 2014, health insurance exchanges are supposed to provide one-stop shopping to help individuals and small employers find affordable private health plans. HHS said Early Innovator states will develop the building blocks for Exchange IT systems, providing models for how Exchange IT systems can be created. This will help other states build their Exchanges quickly using the models and building blocks created by the Early Innovator states, without having to start from scratch.
The Early Innovator states are:
Kansas: Kansas Insurance Department, $31,537,465
Maryland: Maryland Deptartment of Health and Mental Hygiene, $6,227,454
Multi-State Consortia: University of Massachusetts Medical School, $35,591,333
New York: New York Department of Health, $27,431,432
Oklahoma: Oklahoma Health Care Authority, $54,582,269
Oregon: Oregon Health Authority, $48,096,307
Wisconsin: Wisconsin Department of Health Services, $37,757,266
The innovator states represent different parts of the country, and different exchange governance structures and information systems, to ensure that a wide range of IT models are developed, and every state will benefit, HHS said.
“Everyone wins,” said Don Berwick, MD, administrator of the Centers for Medicare & Medicaid. “This grant program means that states don’t have to waste money reinventing the wheel, and consumers get the best of the best.”
The Department of Health and Human Services on Wednesday unveiled a new National Vaccine Plan – the first major revamp since the plan was created in 1994 -- to coordinate and improve public access to federal vaccine and immunization programs over the next decade.
The new 10-year plan addresses a range of issues, including research and development, supply, financing, distribution, safety, global cooperation, and informed decision-making among consumers and healthcare providers, HHS said.
"Vaccines are a critical cornerstone of the public health system," said Assistant Secretary for Health Howard K. Koh, MD. "The National Vaccine Plan articulates a vision that will ensure that the nation's prevention strategies protect the public for the next decade and beyond."
Many Americans still suffer from infectious diseases that can be prevented by vaccines, and the updated plan calls for improve delivery of existing vaccines and to spur development of new products to prevent infectious disease. The National Vaccine Plan uses input from public health and medical experts, federal, state, and local government officials, and the public, HHS said.
"This plan is a 10-year vision for the nation to more effectively prevent infectious diseases and reduce adverse reactions to vaccines," said Bruce Gellin, MD, director of the National Vaccine Program Office and Deputy Assistant Secretary for Health. "The plan is national in scope. Implementation will require a well-organized effort among stakeholders, including federal, state and local policymakers, health care providers, manufacturers, academia, philanthropic organizations, and the public."
HHS will sponsor regional meetings with stakeholders this spring and summer, which will focus on implementing the strategies in the plan. Final implementation of the plan will be completed by the end of the year.
Three Florida physicians were among the 20 people charged Tuesday in federal court in Miami on healthcare fraud, kickback and money laundering charges for their alleged roles in a $200 million Medicare fraud scheme, federal officials said.
The 38-count indictment unsealed Tuesday in U.S. District Court in the Southern District of Florida alleges that the defendants created and worked with American Therapeutic Corp. and Medlink Professional Management Group Inc., to defraud Medicare by submitting false claims for mental health services that were unnecessary or not provided, according to a joint media release from the Department of Justice, and the Department of Health and Human Services.
U.S. Attorney Wifredo A. Ferrer in Miami said the case shows that Medicare scams have evolved from DME fraud, to infusion fraud, to home healthcare fraud, to community mental health treatment fraud. "Worse yet, healthcare fraud has come to permeate every level of the healthcare industry, from the owners and managers of dirty clinics, to complicit doctors, program directors, therapists, marketers, and patient recruiters," Ferrer said.
The indictment alleges that the defendants paid kickbacks to patient brokers and owners and operators of halfway houses and assisted living facilities that delivered patients to ATC clinics. The defendants are charged with money laundering related to the cash-for-kickback payments. Sixteen defendants were arrested Tuesday in the South Florida, and more arrests are expected in the coming days.
ATC and Medlink owners Lawrence S. Duran, Marianella Valera, Judith Negron and Margarita Acevedo, were first indicted in October, along with the corporate entities, ATC and Medlink. A superseding 38-count indictment unsealed Tuesday charges them with additional offenses.
Prosecutors said Miami-based ATC operated purported partial hospitalization programs in seven different cities in Florida, from Homestead to Orlando, and that Duran and Valera ran the fraud, kickback and money laundering schemes, Negron abetted them, and Acevedo ran the kickback scheme.
Physicians Mark Willner, MD, Alan Gumer, MD, and Alberta Ayala, MD, were medical directors for ATC, and prosecutors allege that the trio signed false patient charts authorizing unnecessary treatment or continued treatment for patients who were not eligible for PHP treatment, without examining the patients or the charts.
Willner, Gumer and Ayala also allegedly altered diagnoses and medication types and levels to falsely make it appear that the patients qualified for PHP treatments, and manipulated the length of patients' stays in order to maximize the number of days Medicare would pay for the PHP services, prosecutors said.
According to a separate civil complaint, ATC routinely admitted patients to the PHP program who suffered from Alzheimer's and dementia and were ineligible for the PHP program because their mental capacity did not allow them to benefit from group therapy.
The indictments allege that the kickback scheme was supported by a money laundering scheme that issued checks in the names of the defendants or shell corporations they created, cashed the checks and returned the cash to Duran and Valera, who paid the kickbacks.
Earlier this month the Office of the Inspector General for the Department of Health and Human Resources posted a list of 'most wanted' Medicare fraudsters.
The major trade groups for healthcare providers offered a decidedly mixed reaction to President Barack Obama's Fiscal 2012 budget proposal released Monday, with doctors praising the plan and hospitals panning it.
The American Medical Association looked favorably upon the president's plan to shift about $50 billion in Medicare and Medicaid payments away from states, insurers and drug companies over the next 10 years, and use the money to improve physician reimbursements.
"Based on preliminary reports, the AMA is pleased that President Obama's proposed budget includes funding to address Medicare physician payments and medical liability -- two broken policies that are driving up cost and compromising patients' access to physician care in our nation," said AMA President Cecil B. Wilson, MD.
"Permanent reform of the Medicare physician payment system is essential to ensuring seniors and baby boomers now entering Medicare can receive the physician care they deserve. The president's budget includes a renewed commitment to permanently fix the broken Medicare physician payment system, which the AMA strongly supports. It also contains funding to delay the devastating cuts scheduled to occur Jan. 1, 2012 for another two years, which is important for providing stability in the Medicare system while a permanent solution is enacted."
Wilson said the AMA was also pleased to see funding included in the budget for "testing innovative medical liability measures (as) an important way to augment efforts to enact the proven reforms such as those included in the HEALTH Act (HR 5)."
"The AMA supports the proven medical liability reforms in HR 5, which have been shown effective in states such as California and Texas, as well as the testing of innovative measures such as those funded in the President's budget proposal," Wilson said.
American Hospital Association President Rich Umbdenstock said the trade group was "deeply disappointed" that the president's call for about $18 billion in Medicaid cuts over the next decade.
"At a time when hospitals have already been asked to absorb big cuts at the state level, and state budgets are already stretched, it is unwise to ask states to continue to do more with less," Umbdenstock said. "In addition, we are also disappointed to see elimination of funding for the children's graduate medical education program at a time when there is a need for an expanded physician workforce. While we fully support eliminating future reductions to physicians, the answer to the physician payment issue is not cutting one provider to reimburse another."
With the recent theft of an electronic medical records file now confirmed, New York City officials have begun the arduous process of notifying 1.7 million patients, staff, contractors, vendors and others who were treated or who provided services during the past 20 years at two public hospitals in the Bronx.
The New York City Health and Hospitals Corporation said the theft could endanger the personal information of basically anyone who shared personal information with Jacobi Medical Center, North Central Bronx Hospital, or their offsite clinics, which comprise the North Bronx Healthcare Network.
The stolen electronic records contained personal information, protected health information, or personally identifiable employee medical information. Personal information can include social security numbers, names, addresses, and other information that may be used to identify individuals. PHI can include personal information and patients' medical histories. PIEMI can include personal information and employees' health information.
HHC said in a statement that it “values and protects individuals' privacy and confidentiality and deeply regrets any inconvenience and concern this may create for patients, staff and others affected. The loss of this data occurred through the negligence of a contracted firm that specializes in the secure transport and storage of sensitive data.”
There is no evidence that the data have been inappropriately accessed or misused, HHC said. However, HHC is providing information and one year of free credit monitoring services to anyone who may be worried about possible identity theft.
Here's a pop quiz on street gang affiliation: Can you tell the difference between a Crip and a Blood, or a Latin King, a Neta, an Aryan Brother, a Pagan, or an MS13? More importantly, can your staff identify a gang banger when he walks through the doors of your emergency department seeking treatment, or helping a wounded "posse" member with a work-related injury?
So far, we appear to have dodged a bullet – literally and figuratively -- on the issue of gang violence spilling into the hospitals. Violence, however, is intrinsic with street gangs, and there is an uneasy fear that at some point, somewhere, rival gangs seeking treatment for their injured friends could confront one another in the emotionally charged confines of an emergency department.
Police estimate that there are hundreds of thousands of gang members of every race and ethnicity in every state in the union. That being the case, it's probably a good idea to provide staff with education on street gangs, how to spot them, and how to respond when they're in your ED to defuse potential violence.
Since 2007, hospital and law enforcement officials have been preparing for that contingency. The New Jersey Hospital Association has worked with the state's Parole Board to offer a one-day crash course called "Gang Awareness Training for Healthcare Workers."
Mary Ditri, director of professional practice NJHA, said the hospital trade group decided to address the issue before a violent gang-related incident occurred. "We know this is something our communities struggle with, gang violence, and it's not going away," Ditri says. "The training is really not geared to have healthcare workers do things they shouldn't be doing. It's geared toward giving them the tools they need to help them do what they do better, focusing on environmental safety for the patients, their families and the providers and their colleagues."
Lt. Daniel Riccardo, Field Coordinator for New Jersey State Parole Board Street Gang Unit, has brought gang awareness to dozens of hospitals across the Garden State. "I couldn't give you an exact number statewide of how many gang members there are in New Jersey. Let's put it this way: a lot," Riccardo says. "They should all be considered a threat because they have a violent nature that can come out at any given time."
"When one of them gets shot, or stabbed, or beaten up, where are they going to go? The ER. And the first people they are going to deal with are ER staff," he says.
Chances are that injured gang member and his running buddies aren't looking for trouble at your hospital. You aren't a threat to them, and they need treatment. The problem is what happens if the rival gang shows up. Maybe they've got a wounded friend who needs treatment too. That's when things get dicey. "If you have reason to believe you have a gang member you may want to put them in a separate room. You may want to put them off to the side so they aren't in the main view of the general public," he says.
It sounds easy to "profile" a gang member. Maybe he's wearing red or blue clothes, or he's covered with tattoos, of flashing hand signals. Maybe there are five guys in the waiting room dressed like him. They might be gang members, or not. Unfortunately, there really isn't one iron clad signal that will announce the presence of a gangbanger. "Self admission alone isn't good enough. Just because you tell me you're a Blood that is not enough. You could be a wannabe," Riccardo says.
Instead, he says hospital staffs need to understand a wide array of clues and behaviors that could signal gang affiliation and if suspicions are aroused, call the police. "I emphasize, do not confront them or ask: 'what crew are you running with?'" Riccardo says. "I don't want hospital personnel to say anything in regards to gangs with someone you believe is in a gang. I'm just saying if you have reason to believe let somebody know and let them deal with it. It's a safety issue. If law enforcement comes to the hospital, they talk to the person and he isn't a gang member, so be it. I would rather be safe than sorry and have a violent incident in the ER."
Riccardo says the gang awareness program is something that could easily be replicated in other states, because there are gangs in every state in the union, "including Hawaii and Alaska."
You may even consider expanding the scope of the training to include domestic violence, which perhaps poses an even greater threat to patients, and providers if the angry spouse walks into the ER.
We cannot control much of what goes on outside of the hospital doors. It's hard enough to control who walks through the hospital doors, with 24/7 access to everybody required by Emergency Medical Treatment and Active Labor Act (EMTALA) and usually with no security screens to walk through. That's why it's imperative that hospitals have a plan in place to react to violence. Even better, provide staff with the tools to identify the potential for violence before it occurs.