Forget Hillary Clinton and Barack Obama. The political battle you want to keep an eye on this spring is the fight between two of healthcare's biggest associations over the merits of physician-owned specialty hospitals.
This certainly isn't a new debate. As the number of physician-owned hospitals has risen dramatically since the 1990s, hospitals and a handful of others in the healthcare industry have questioned the safety of these facilities and raised red flags about the potential for self-referrals and other financial conflicts of interest. Congress has looked into the matter several times and went so far as to impose a moratorium on physician referral to new specialty hospitals between 2004 and 2006.
But the hospital industry threw fuel on the fire in April when it lobbied to slip into an unrelated farm bill a provision to ban all self-referrals to physician-owned hospitals (the provision was later dropped). The flames were further fanned the same month when the American Hospital Association released a 12-page report criticizing "physician ownership and self-referrals in hospitals," and again when the AHA, along with the Federation of American Hospitals and the Coalition of Full Service Community Hospitals were accused of misstating key facts about safety in physician-owned hospitals in order to provoke Congressional action. The OIG sent an official letter of rebuke to the hospital associations for misrepresenting the research.
Clearly, hospitals view competition from physicians as a major threat and are doing their best to quash it. But physicians aren't taking it lying down. The American Medical Association, the nation's largest association of physicians, released a scathing critique yesterday of the hospital industry's "campaign to eliminate physician-owned hospitals," accusing the AHA of resorting to "smoke and mirrors."
"[This] has nothing to do with patients, and everything to do with eliminating competition," said William G. Plested, MD, immediate past president of the AMA. "Plain and simple—this is nothing more than a power grab by the hospital industry."
So who's right? Well, as is the case with most political disputes, both sides have a few valid points buried beneath layers of over-hyped rhetoric. Physician self-referrals in general present the opportunity for abuse and contribute to rising medical costs and should be a concern in all settings, particularly in hospitals where physicians have a direct financial interest. But physician-owned hospitals also expand access and provide patients with care options to choose from, and as long as there are checks in place to ensure safety, there's no reason to completely nix the concept.
Perhaps a better question: Is this really what the industry should be focused on right now? Lobbyists representing both sides are making their case to Congress; the AMA and AHA and other associations are spending money, time, and effort on this battle. That's money, time, and effort that could be spent working toward a better payment system or finding a way to cover the nation's uninsured or preparing for the upcoming physician shortage.
The most common office problems—many of them billing issues that can frustrate patients—can be traced back to failure to perform one of five tasks. Create policies to ensure that each of the following five steps takes place automatically:
1. Verify the patient’s current healthcare insurance coverage. For example, the patient may have changed jobs and returns to your practice later in the year with new coverage. The front desk staff assumes the old coverage is valid and does not ask for the new card. As a result, the insurance claim form is sent to the old insurance and is denied. The claim then becomes the patient’s responsibility. The process to finally get the denial from the correct insurance can take months. And often, the patient will get a bill in the mail that he or she is not expecting but is required to pay. This can result in a very dissatisfied patient calling the doctor’s office expecting an explanation. Even worse, the patient may leave the practice and find another doctor.
2. Capture the complete and correct list of all procedures performed. As more and more practices have EMRs, the procedures/services performed for the patient are not captured. For example, a patient receives an immunization during one visit that was never captured and may receive the same immunization on a subsequent visit. This may cause health problems and make patients unhappy.
3. Read the patient’s insurance card carefully and send the claim to the correct address. When staff members do not search for the most current company address, the claim may not reach its destination and must be sent again. While waiting for the claim to be paid, the patient may lose confidence in the practice and decide to change doctors as a result of this mistake. Communications with the insurance company and/or practice may also cost the patient a great deal of personal time.
4. Double-check that you spelled the patient’s name correctly and that it matches the name that appears on the insurance card. In addition, check that you know who the insured party is, as it may not be the patient. For example, staff members assume that the 17-year-old student who is seen in your practice is the insured, when in fact, it’s the patient’s father. As a result, the claim may be denied and the balance will be transferred to the patient. Now, the patient will get a bill for services he or she does not actually owe because he or she does have adequate coverage but the claim was filed incorrectly.
5. Make sure that a referral or preauthorization is obtained for all services that require them. For example, if a staff member schedules a flexible sigmoidoscopy before the patient comes into the practice, but doesn’t follow up to see whether the service is preauthorized with the insurance company, the procedure may have to be rescheduled, greatly inconveniencing the patient.
Shannon Sousa is the editor of The Doctor's Office. She may be reached at ssousa@hcpro.com. This story was adapted from one that first appeared in the March edition of The Doctor’s Office, a publication by HealthLeaders Media.
What makes physicians so unhappy? I ask myself this when I end angry phone calls with frustrated physicians or when a surgeon walks through the emergency department at my hospital spouting a tirade of profanity that makes the paint peel off the wall. And I wonder about it when I hear a potential medical student talk to a physician, who tells the bright eyed young man or woman, “Don’t do it!”
I have my theories. That’s because the ER is a great place to watch, listen, and learn. I trained in a large urban teaching center and have practiced in a busy, semi-rural community hospital for 15 years. What I’ve seen is a lot of frustration. The question is, what can we do to ease that frustration and create a happier, more functional medical workforce?
First of all, I don’t think that physician unhappiness has to do with patients. Every physician has his or her favorite story of the nightmare patient—like the one who calls at all hours for Viagra refills, the patient the who insisted to my partner that she be admitted for her bad perm, or the drunks who play with rattlesnakes. But patients have been difficult as long as anyone has pretended to be a healer. And frankly, they entertain us; the weirdness we see keeps us coming back, voyeurs of human silliness that we are.
Physicians are sometimes unhappy because we’re busy. We belong to committees, go to meetings, attend CME conferences, educate students and residents, see patients, volunteer in the community, and still try to squeeze in family time (often as an afterthought). We don’t often say no; certainly not often enough for our own good.
And, as always, there’s money. With reimbursement falling and the number of uninsured patients rising, turning a profit in medicine can be very hard. The costs of regulatory compliance, filing insurance, and paying malpractice alone are enough to make medicine unprofitable for many physicians; so they become more and more dissatisfied with their careers and lives. Some people think that’s the essence of physician unhappiness.
Breaking the cycle
Making money isn’t exactly the problem. For all our problems with reimbursement, physicians can still make a fair amount. The problem with making money is that we spend it. And when we spend it, we need more. And the battle is joined.
The cycle is understandable. Physicians start their careers in debt—the average medical student graduates with a burden of educational debt that is currently somewhere around $120,000 and starting residency salaries are only around $40,000. After residency physicians need to make an immediate income boost to catch up and cover debt. But he or she also wants to enjoy the money that’s finally in that bank account. So, doctors start to spend money like. . . doctors.
When we’re not careful, we throw money around like Columbian drug lords in Vegas. The problem is, their money does not depend on hours worked or patients seen; physician income does. We get our cash by seeing patients and performing procedures. We make money on effort, not on money itself. We more resemble factory workers or building contractors than bankers or investors.
So, in order to maintain wealth, we have to keep working hard. And if we spend more, we have to keep working harder to pay off debts. Working harder is tiring, and keeps us away from our families and hobbies. And the cycle goes on and on.
Then, if we wake up unhappy one morning, or realize our families are dissolving before our eyes, or if we feel a desire to cut back, we simply don’t have a choice. We are enslaved to a certain level of income. However miserable the practice may be, we’re stuck. If the partners are hard to work with, or the administrators won’t listen to our problems, we have to smile and keep coming back. If the patients are more and more complex and less rewarding, we have to continue seeing them. If the depression is overwhelming and we actually consider suicide (doctors have the highest suicide rate of any profession), we feel guilty admitting it or seeking help; after all, there’s work to be done and money that needs to be made! So we go on and on, falling deeper and deeper into misery.
In our unhappiness, we also mess up our relationships. This can be an expensive problem; just ask any physician who is now working twice as hard to pay for wife one and wife two, along with child support.
My point is this: It isn’t what we make, but what we need, that enslaves us. If physicians want to be free to enjoy life, free to move, free even to rebel or quit, they have to need less. And perhaps the wisest thing that our directors, partners, or even employers can do is to remind us of this. Frequently. Rather than encourage lifestyles that require large infusions of cash, we should encourage reasonable lifestyles that allow large infusions of time-off and happiness.
If we physicians can just learn, we’ll find that the happiness and contentment we want may be easier to attain than we think. If you’re just starting out on your medical journey, don’t spend money you don’t have in anticipation of how much you’ll make. Because if you do, the act of getting that money will be harder and more painful with every passing year. And the things you purchased as part of the ‘doctor life’ will give you less and less joy.
My friend Robby said it best, in his finest South Carolina accent. “Grandpa always said that the key to happiness wasn’t to get what you want, but to want what you have.” It doesn’t get any simpler than that, does it?
Edwin Leap is an emergency medicine physician and writer living in South Carolina. For more information, visit www.edwinleap.com.
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The Federation of State Medical Boards is working on a policy that would require physicians to demonstrate their continuing competence in order to get relicensed. The draft proposal would require physicians to take part in ongoing self-assessment and demonstrate competence in their areas of practice.
The U.S. Department of Justice has intervened in a whistle-blower lawsuit alleging improper financial kickbacks were arranged between a hospital and large medical group in Ohio. The lawsuit alleges that Christ Hospital, a full service Cincinnati-based hospital and formerly a member of The Health Alliance, and Ohio Heart, the largest cardiology group in that region of the state, devised a scheme that provided cardiologists improper financial incentives in exchange for generating revenue for the hospital.
Harvard psychiatrist Michael Kahn has created a checklist to improve physician etiquette in the exam room. The checklist is designed for physicians to follow during a first-time encounter with a patient, and includes basic reminders like "shake hands" and "sit down."
A growing number of physicians are pursuing a master's degree in business after medical school or in the middle of their careers. Many doctors say an MBA degree is proving vital for many in the medical profession, especially given the constant changes in the business side of their profession.
Recently the Centers for Medicare and Medicaid Services indicated its intention to move forward with measures to support value-based purchasing, a system where Medicare pays hospitals based on the quality of care delivered and patient outcomes. However, CMS failed to state whether the value-based model will transition healthcare to a new model or create the worst case scenario, a hybrid model where performance only partially counts and regulation requirements remain heavy.
In mid-April, Medicare proposed adding nine new conditions, such as bed sores, to a growing list of complications that Medicare won't pay to treat if they were acquired at the hospital. Granted, the government has only proposed these additions, but the message is clear: Medicare doesn't want to cover instances where hospital mistakes or less than optimal care contribute additional cost to the hospital stay.
At first glance, not paying for ineffective care makes sense. However, Medicare offered these changes with no direction as to how they relate to existing measurement standards. In addition, some of the medical complications are very difficult for hospitals to detect or prevent. Further, Medicare also is asking hospitals to begin reporting on 43 new quality measures in order to receive full payment. The prospect remains for the government to add other conditions, too.
The previous push for onsite hospital accreditation, including Joint Commission reporting, could be considered reasonable as hospital quality and safety data were not readily available. With the recent and accelerated push for transparency of performance information, it seems less realistic to continue to ask hospitals to meet accreditation standards that were designed as approximates for quality. In fact, hospitals are currently forced to make the tough decision of how many resources to allocate toward accreditation activities while still meeting the new performance standards.
Imagine that performance only partially counted in golf. We would have tournament officials stating Tiger Woods gets partial credit for his performance but the officials need to investigate whether his swing is consistent with the idealized swing before he could be considered the champion.
Providing quality care for patients is always the ultimate goal. However, there are limited resources available for healthcare, and hospitals can expect to spend hundreds of millions of dollars to meet the new quality measures. The last thing we want is for hospitals to be forced to divert resources and funding from direct patient care.
To be truly efficient, measurement standards need to take into consideration the succession of administrative requirements they trigger in a hospital. Further, as the conditions being reviewed become less precise, the costs of mechanisms needed to ensure reliable coding and comply with mandates, in addition to the cost of enforcement should be determined. While saving money may not be CMS’s sole objective, performing some sort of risk/benefit analysis is certainly warranted.
We also must be aware of the unintended consequences. The first set of conditions for which no payment will be made hasn’t even been implemented yet. Therefore, we don’t have the benefit of understanding the impact of these newest standards. Moreover, it’s worth considering whether CMS is even equipped to manage and process data effectively to ensure accurate payment to hospitals that meet the standards, which is important given that hospitals are already financially fragile. We would gain substantially from a “test run” with the first set of rules before launching into a discussion around nine additional new conditions.
These new guidelines bring focus and attention to hospital performance in an important and worthwhile way. However, simply adding another layer of reporting measures is not going to magically improve hospital performance —particularly if they are already burdened by outdated modes of looking at quality.
If quality patient care is the goal, then performance is what truly matters. Now that we have systems to measure performance in precise areas of patient care, perhaps other performance measurement burdens could be reduced. Otherwise, it calls into question whether performance really matters. If performance truly matters, it seems it can't be for partial credit.
Trent Haywood, MD, is senior vice president and chief medical officer for VHA, Inc., an Irving, TX–based healthcare alliance that provides supply chain management services and networking opportunities for hospitals and healthcare providers. Read our editorial guidelines to find out how you can contribute to HealthLeaders Media.
Clostridium difficile, or C. diff, isn't a new name to those who work in a hospital. But CMS' recent proposal to include the infection on its list of "never events" and figures released recently by the federal government have brought increased media attention to the hospital-acquired infection. And with a new, more drug-resistant strain making its way through our facilities, maybe it's time that we start paying more attention, too.
The last time a patient was discharged from your hospital, you probably made sure that a cleaning crew quickly readied the room for the next patient. They changed the linens, mopped floors, and wiped down counter surfaces. But do you know what kind of cleaning solution they used? Did they thoroughly wipe the phones, the call buttons, the bed rails, and other commonly-touched items?
If you can't confidently say "yes" to all of these questions, it may be time to start paying attention to how well your hospital is cleaned. Two weeks ago, my colleague Gienna Shaw wrote about how important clean facilities are to the image of a hospital, but cleanliness is more than image. With drug-resistant strains of C. diff and MRSA invading our facilities, cleanliness is a matter of life and death. To combat these infections, we have to make sure that our hospitals are not just spotless, but infection-less. Passing the white glove test is no longer an acceptable standard.
Curtis Donskey, MD, director of infection control at the Louis Stokes Veterans Affairs Medical Center in Cleveland, says that this newer, tougher strain of C. diff is why we're seeing so many more cases of the infection—both inside and outside of the hospital. While regular cleaning solutions used to be effective in wiping away C. diff spores, this new strain is tougher to eradicate and is more likely to be transferred from person to person through spores left on surfaces.
"You can go into a room and it looks clean, but it's not until you look closely that you can appreciate the contamination," Donskey says.
That's why at the VA Medical Center, cleaning crews are now using a solution that is 10% bleach to disinfect rooms between patients—but they're not just wiping down the tray tables, call buttons, and doorknobs. They're spraying the solution directly on the surfaces and allowing it to dry there.
"There is evidence that C. difficile is not killed by regular hospital disinfectants that are used to kill other pathogens," he says. A solution with 10% bleach, however, has shown to be effective in killing C. diff spores. "The major issue is not whether it kills, but how well you apply it. Spray it on and let it air dry. It takes contact time to kill the spores."
At Pacific Hospital in Long Beach, CA, controlling infection is a matter of simple hygiene for both the facility and its patients, says Alfonso Torress-Cook, MD, hospital epidemiologist. Over the last eight years, the rehabilitation hospital has completely reevaluated how its hospital rooms are cleaned and instituted a policy that all incoming patients are bathed with a special solution that eliminates C. diff pathogens from skin, he says. The result has been a 90% reduction of C. diff infections at the hospital.
"We made a commitment two years ago to make everything possible for our patients not to develop infections," says Torress-Cook. "We can prevent a lot, and we're trying our best. Am I going to say that I just want to prevent 30% of infections? No. I want to get to zero. Some say I'm crazy, but at least it's a goal and we are seeing results."
"Superbugs" like MRSA and C. diff aren't going away unless we collectively send them packing. Thanks to CMS and the media, there's now increased pressure for hospitals and healthcare organizations to do everything they can to make sure that facilities are not just clean, but super clean. If you haven't paid much attention to the cleaning of your facility lately, it's time to take interest, before the "superbugs" take control.
Carolyn Scanlan, president and CEO of the Hospital and Healthsystem Association of Pennsylvania, explains how the state's annual infection report is encouraging the state's
165 acute care hospitals to work for improvement.
