A simple blood test may be able to predict the likelihood that a patient with congestive heart failure will be readmitted to the hospital or die within a year of a hospital discharge, says a study published in the online issue of the American Journal of Cardiology. The inexpensive blood test, performed at admission and again at discharge, can help doctors make important decisions about care, and reduce the risk of costly readmissions.
Researchers examined heart failure patients on admission and discharge to determine levels of a certain protein (NT-proBNP) that's a marker for heart stress. They found that if a patient's levels decreased by less than 50% during their hospital stay, they were 57% more likely to be readmitted or to die within a year than those who experienced a larger drop.
The study group consisted of 241 patients admitted to Johns Hopkins Hospital in Baltimore for congestive heart failure between June 2006 and April 2007. They underwent the NT-proBNP test at admission, and the patients' doctors then treated their symptoms throughout the hospital stay. Researchers re-tested the protein level at discharge, and patients' treating physicians were not made aware of the level change. Researchers then followed up with hospital records, patient family interviews, and death records over the next 12 months.
Hospitals typically test CHF patients for this protein when they are admitted, but not when they are discharged. Instead, other clinical factors are relied upon to determine whether a patient is healthy enough for discharge. Physicians typically consider a patient's function, heart and lung sounds, and weight loss, among other factors.
Dr. Henry Michtalik, M.D., M.P.H. a clinical fellow in internal medicine and a hospitalist at Johns Hopkins Hospital, and lead researcher on the study, explained that physicians don't typically test NT-proBNP levels at discharge since the number alone may not be significant. A number that could be suspicious for one patient might be insignificant in another.
However, because the research looked at the percent change between the two numbers, doctors would be comparing how a patient is doing from the time of admission to the time of discharge.
"This test is a way to stratify who is at the highest risk of readmission or death," Dr. Michtalik said. "You could see a certain percent change and know that you need to be more aggressive at the outpatient setting, plugging the patient into resources sooner, or titrating the medication in a certain way."
Dr. Michalik was somewhat surprised by the study results. "It seemed like a simple concept to test the same marker at discharge. I can understand why there is hesitance since you don't want to treat to achieve a certain number, but it is a way to stratify," he said. He added that the blood test costs about $50, depending on the institution.
About 5 million people in the United States have congestive heart failure. CHF causes about 300,000 deaths in the United States each year. According to an article published last year in the Archives of Internal Medicine, the cost of treating CHF varies widely from hospital to hospital. Researchers found that the cost of treating a patient for CHF ranges from about $1,500 to about $18,000.
When you’re scrambling for revenue anywhere you can find it, terminating a managed care contract may sound like the last thing you should do. But in fact, getting rid of a contract that is not working for you can actually make your practice more profitable.
Physician practices often hold on to contracts that are not profitable because they have had a relationship with that managed care provider for years and losing it would seem like a financial loss, says John Schmitt, a managed care expert with EthosPartners Healthcare Management Group, based in Suwanee, GA. However, a close analysis of the numbers may show that the contract is not producing any revenue for your practice—in fact, it may actually be costing you money, says Schmitt.
“We can be reluctant to let go. People often think anything is better than nothing, but with managed care contracts that’s not always true,” he explains. “If you have a bad contract or a bad business partner, it can be very resource-consuming for the practice because it will take a lot of time and require a lot of hassle.”
A practice also may be reluctant to terminate a contract because a personal relationship has been established, Schmitt says.
“Often the payer is represented by a very cordial, nice person and you don’t want to tell them no,” he says. “So you renew the contract, and then months later you ask yourself why you ever signed this contract in the first place. You have to not make it personal and just say you don’t want contracts that don’t work for you.”
Broken promises often the cause
Termination frequently is prompted by payers who have unreasonable fees or aren’t responsive to problems such as claim denial rates and pre-authorization rates that are difficult to work with. Another common reason for terminating a contract is the payer not fulfilling promises it made when trying to get you on board, Schmitt says.
“It can be like a divorce: too many irreconcilable differences and you just can’t work it out,” he says. “Breaking up is not something you want to do, but you just can’t go on like that.”
Managed care contracting is becoming more complicated than in years past, Schmitt says, particularly with the growing popularity of incentive-based payer programs. These arrangements can hinge on promises that, if unfulfilled, may form a reasonable basis for terminating the relationship, he says.
The incentive arrangements require a great deal of trust between the two parties, Schmitt says. If the managed care provider is not transparent, cooperative, and willing to resolve problems, the arrangement can fall apart.
Detecting a lack of trust should put you on the alert that this may not be a contract that is worth keeping, Schmitt says. Warning signs can be a pattern of delayed or denied claims that seem unreasonable, a failure to respond in good faith when the practice reports concerns about transactions, or overly burdensome requirements from the payer, he says.
“When there’s no trust, the negotiations are slow, and because they’re slow, you lose revenue you could have made in the meantime, and it’s more costly in terms of the time it consumes,” Schmitt says. “So it actually results in a trust tax, so to speak.”
Not the time for emotion
So when it comes time to say goodbye, how do you do it? The first rule is to make the termination strictly factual and not emotional, Schmitt says. All communication should be respectful, and you should document why you have decided to end the relationship, he says.
“You should present it to them in a very clear way, saying, ‘These were our expectations and these are what the results were. We expected these things and you did not deliver. You didn’t keep your commitment to what you said you were going to do.’ They deserve to know why you’re terminating the contract, but this is not the time to get angry or tell them how frustrated you are. Simply state the facts calmly and leave it at that.”
Although terminating a contract can be the right business decision, do not take the decision lightly, Schmitt says. Remember that terminating a contract will cause some headaches for you.
Not likely to come back
For starters, you must give notice to patients covered by that payer, and the patients will not be happy about the news, Schmitt says. Patients should be notified individually, and a notice should be posted in the lobby stating that you no longer accept the payer’s coverage, but you will still see the patients if they wish to self-pay.
“The front office should be prepared to convey this information and discuss it in a caring way because this is a difficult issue for patients. They take it personally,” he says. “You can’t just say, ‘Oh, we don’t take that anymore.’ ”
Don’t terminate or threaten to terminate a contract in hopes of getting a better offer from the payer, Schmitt says. If the payer were going to make you a better offer or provide better service, it already would have before you got to the point of termination. Likewise, don’t expect the payer to court you in the future. The relationship will be strained at best, he says.
“Will they come back later and try to make it all better, change their ways and give you better rates?” Schmitt says. “Well, some divorced couples get back together. But don’t count on it. Usually it takes a new era of management to come in at the payer and change things around, then they try to show you they don’t have the same problems as before.”
Two senators, a Republican and a Democrat, are pushing legislation to overturn a 1979 court injunction that bars the public from seeing what individual physicians earn from Medicare. That data, commonly known as the Medicare claims database, is widely considered one of the best tools for identifying fraud and abuse in the $500 billion federal health-insurance program for the elderly and disabled. Last year The Wall Street Journal, together with the nonprofit Center for Public Integrity, obtained from the government limited access to the database. Despite severe restrictions on the data, the paper was able to mine it and expose through a series of articles how doctors and other medical practitioners appear to be gaming Medicare to increase their profits. One physical therapist identified by the Journal as having suspicious billing patterns was indicted last month on charges of defrauding Medicare.
Doctors with older patients hear clues all the time. Elderly people mention, in passing, that they are missing money or that they signed forms they did not understand. Or maybe they can't find a treasured possession like a watch or a wedding ring. But doctors traditionally have not been trained to recognize that confusion or forgetfulness can be signs that the patient is at financial risk, said Robert W. Parker, MD chief of community geriatrics in the family medicine department at the University of Texas Health Science Center in San Antonio. "We give them another pill, device or test. We don't always spend time with patients so we get to know their concerns," said Parker. "And medical doctors have not wanted to mix medicine and money." But now he, along with thousands of other doctors and medical professionals across the country, are taking part in a new effort to screen older patients for financial vulnerability as well as indications they are being exploited financially by family members, friends or strangers.
Managers at Washington Hospital Center and the nurses union are bracing for a planned strike Friday at the region's largest hospital, with managers flying in replacement nurses from all across the country and nurses seeking support from city officials. The nurses' contract expired last spring, and the two sides have been engaged in a rancorous dispute over wages, benefits, staffing and patient safety. The union represents about 1,600 nurses. If a strike takes place, the 926-bed hospital will be fully staffed, with all units open, according to an e-mail sent to hospital physicians Wednesday by Janis Orlowski, MD, the CMO at the facility. The job action is supposed to last a day, from 7 a.m. Friday to 7 a.m. Saturday. But hospital officials said they will lock out striking nurses for five days, meaning that they will not be allowed back to work until Wednesday and will not get paid for those days. Hospital officials said they are doing so because they are obligated to pay 600 replacement nurses for a minimum of 60 hours of work, typically five 12-hour shifts.
The U.S. Supreme Court this week sided with a former Proctor Hospital employee who claimed he was fired by the Peoria, IL hospital because of his military service and, in the process, potentially resolved a long-standing legal issue regarding workplace discrimination. By an 8-0 decision, the Supreme Court agreed with Vincent Staub that his military service was a factor and that employers such as Proctor can be held liable for the actions of their employees. "An employer's authority to reward, punish, or dismiss is often allocated among multiple agents. The one who makes the ultimate decision does so on the basis of performance assessments by other supervisors," wrote Justice Antonin Scalia. "We therefore hold that if a supervisor performs an act motivated by anti-military animus that is intended by the supervisor to cause an adverse employment action, and if that act is a proximate cause of the ultimate employment action, then the employer is liable" under the federal anti-discrimination law for members of the military, Scalia wrote. The theory, dubbed the "cat's paw," has divided the appellate circuits as some wanted more direct links of bias along the supervisory ladder.