The two presidential candidates take very different approaches to healthcare reform, but they both agree that Medicare needs a new system for physician reimbursement. Their advisers have suggested both would shift the system away from the current model, which gives doctors a financial incentive to do lots of high-end procedures, even if they are not entirely necessary, according to this blog posting in the Wall Street Journal.
Foiling the drug-seeking patient involves more than the physician. It's a collaborative effort that's a clinical and practice-management issue.
The following tips can help to create an office environment that discourages drug seekers:
Appearances matter. Run a clean, neat office that doesn't look like it's a place for drug seekers.
Have consequences. Too few practices terminate their relationship with patients who are trying to game the system. Termination may not always be the right approach, but there need to be consequences.
Ask questions. You want to have the reputation as a practice that asks questions. It's part of taking a thorough history. Among the questions to consider:
What other providers have you seen for this condition?
What drugs are you currently taking?
Which pharmacies do you use?
Are you being treated for drug or alcohol dependency?
Ask for picture ID. Ask for a driver's license or state ID and make a copy for your files so you can match a face to a name.
Spread the word. Putting a policy in place is essential. But you must also communicate it to patients. Develop an information brochure that describes the practice's policies, and be sure to include a section on controlled substances. Include information about samples to after-hours refills to drug testing in the brochure.
Practice due diligence. Securing drug samples is common sense, but lapses do occur. It may be time to review your procedures. Likewise, keep track of prescription sheets.
This article was adapted from one that originally appeared in the October issue ofThe Doctor's Office, a HealthLeaders Media publication.
The financial crisis—both within healthcare and in the world economy—was predictably a hot topic of conversation at the MGMA annual conference in San Diego this week, and the latest MGMA cost survey that was released at the event suggests the financial environment isn't getting any better for physicians.
At this point, you don't need me to tell you that operating costs increased faster than revenues for many medical groups last year. That trend has been firmly in place for so long that the relatively small difference this year—multispecialty groups reported a 5.5% increase in revenue and a 6.5% increase in costs—seems predictable and almost mundane.
But when you consider that this pattern has held for more than a decade, the daunting circumstances group practices now face become clear.
Since 2001, operating costs for multispecialty groups have increased an astounding 43.1%, while the Medicare conversion factor for reimbursement is exactly the same. Seeing that data graphed during a presentation this week was alarming—and the slope is only getting steeper.
The natural reaction to this dynamic is to improve efficiency and cut operating costs as much as possible. But any business can only trim fat so far, and most groups have reached the limits of these improvement efforts.
Many of the cost-centers with the biggest increases are crucial to practice operations and difficult to cut:
Drug supplies. Costs of drugs jumped 17% for multispecialty groups, compounding a 33% increase the previous year. Pediatrics was the single specialty hit the worst with a 56% single-year increase, creating an unbelievable 132% increase over the past three years.
Support staff. Some specialties struggled more with support staff costs than others. Family practice, OB/GYN, and pediatric groups all saw double-digit increases in employee-related expenses in 2007, for example.
Professional liability. Cardiology saw the biggest increase in malpractice insurance premiums, 8%—bringing the total increase since 2000 to 132%. However, there was some good news. OB/GYN and orthopedic groups reported a decrease in malpractice costs.
The most troubling aspect of the situation is that there is little relief in sight. It has been a struggle to just keep reimbursement stagnant, rather than sharply dropping, and cost controls aren't doing the job.
Despite the seemingly endless barrage of bad news for medical groups these days, though, the overall attitude at the conference was positive. Hard times tend to spur innovation and change. It may not always be the ideal change—many physicians feel pressure to sell to a hospital or seek employment—but in each problem also lies opportunity, and physician practices are rapidly discovering new practice structures and leadership approaches for the current environment.
Most medical groups are getting by, and don't let the numbers fool you—the most adaptive continue to do very well.
For more information, see some of the reports I filed this week from MGMA:
Elyas Bakhtiari is a managing editor with HealthLeaders Media. He can be reached at ebakhtiari@healthleadersmedia.com.
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University of Miami President Donna Shalala told 100 South Florida healthcare leaders that the key to making major changes was getting a consensus. Shalala, the former leader of Health and Human Services in the Clinton administration, noted the country had never "taken a giant leap" in any large social change without first getting agreement that there was a problem and then getting agreement on what the solution should be. The seven panelists who followed her during a discussion at UM's Wellness Center agreed that the system needed huge reforms, but there was no consensus about what should be done.
The new independent board overseeing Cook County, IL's vast public health system wants an extra $103 million next year and permission to hire more than 400 new workers. The panel's chairman is defending the request as a needed first step before the troubled operation can be made more efficient, with fewer employees and more money collected from patients and their insurers. The board is also conducting studies to determine how to cut about 500 employees, although the 2009 spending plan calls for adding about 415 workers, mostly doctors and nurses. This is because the skills of those who are needed in new spots and those who aren't needed in their current posts don't match, said the health board chairman.
There is a nagging myth out there that it is the approximately 47 million uninsured people in this nation who are clogging hospital emergency rooms for routine care better suited to a doctor's office or a walk-in clinic.
A new study in the current issue of the Journal of the American Medical Association reaffirms what many already know—this is not the case.
The JAMA study, Uninsured Adults Presenting to US Emergency Departments: Assumptions vs. Data, looks at 127 previous studies of emergency medical and surgical care for uninsured adults and found that 53 of those studies carried assumptions about uninsured ED patients that weren't borne out by facts.
"The uninsured have become a scapegoat," says Manya F. Newton, MD, an emergency physician at the University of Michigan and an author of the study. "There is a belief among some people that the uninsured are choosing to be uninsured because they are lazy, and that if they worked harder they could get insurance and all our problems would be solved."
The JAMA study acknowledges that the uninsured population is growing. The numbers of uninsured in hospital EDs are growing, too. And yes, many uninsured use the ED because they lack access to primary care. All true.
However, the JAMA study identifies unsupported assumptions in a number of studies about the uninsured; namely, that they were the main cause of ER overcrowding; and that they have less-serious conditions than insured patients and use the ED as a matter of convenience.
"These studies weren't subtle at all," Newton says. "We see in quotes 'uninsured patients realize that no matter what complaint they have, even if it's not an emergency, they can get care in ED for free.' Or 'it is widely understood that the uninsured show up for non-urgent problems.' These statements are made with no citations," she says.
The CDC in August found that the uninsured make up 17.4% of ED visits. Patients with government sponsored health plans, and privately insured patients, make up about 42% and 40% of the ED volume, respectively. The CDC also reports that ED visits increased 32% nationally from 1996 to 2006, from 93 million to 119 million visits. At the same time, the number of EDs decreased from 4,019 to 3,833, exacerbating crowding.
It's easy to understand why the general public—especially someone who's just waiting three hours for emergency care—might have an exaggerated sense of the problems that the uninsured are creating in the nation's EDs. Newton says it's difficult to explain why the myth continues to thrive among well-educated healthcare professionals who really should know better.
"It's easy to confuse anecdotes with data," Newton says. "If you are on the front lines of a busy emergency department, it's easy to remember the person who shows up for the sniffles who makes you mad rather than the 300 people who showed up appropriately."
"It becomes part of the common culture," Newton says. "I was guilty of some of these assumptions myself. And I hear them repeated again and again from my colleagues. Then it becomes something that everybody knows and nobody questions."
John Commins is the human resources and community and rural hospitals editor withHealthLeadersMedia. He can be reached at jcommins@healthleadersmedia.com.
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