It's been a very busy week in Washington, DC—especially if you cover issues related to quality and healthcare. From the meeting rooms of the American Hospital Association's annual membership meeting to the floor of the U.S. Senate to a federal hearing on meaningful use and health information technology, the word has been there: quality.
Quality care is the goal—as well it should be—in reforming the American healthcare system. Who can argue with paying more to hospitals and physicians meeting quality standards? And don't we want to know more about treatments that provide us with quality care? And, how can we eliminate medical errors and improve patient safety and quality care.
But one piece of the picture may be missing. What about the people on the receiving end of that care—which is basically you and me? Of course, we don't want poor or substandard care. But recent polls show that American public may not be totally on board with proposals to change their medical care as much as policymakers think. What may play well in the halls of Congress may be met with some unease in the streets of Peoria or Pittsburgh or Portland.
In the past months, many studies and reports have come out that showed how quality care can be achieved, for instance, through better use of health information technology (HIT) or new Medicare payment methodologies.
But as Peter Neupert, a corporate vice president with Microsoft Health Solutions Group, said at an April 30 presentation on getting HIT right: "Consumers don't want data. They want to make their lives better."
This subtle disconnect between what policymakers want and what consumers want was illustrated in a survey released last week by the Kaiser Family Foundation, National Public Radio, and the Harvard School of Public Health.
An interesting response appeared that included questions about getting medical tests. When asked if too many patients were getting medical tests and treatments that they don't really need, 67% responded it was a major problem, 39% said a minor problem, and 9% replied it was not a problem.
However, when asked if too many patients were not getting the medical tests they needed, a surprising two-thirds (67%) responded that it was a major problem, with 24% saying it was a minor problem, and 7% not a problem.
Also, another question asked was if an expensive medical treatment has not been proven to be more effective than other less expensive treatments, should insurance companies pay for it? More than half (56%) thought the insurance companies should pay it.
In issues now on the healthcare reform table, such as comparative effectiveness research and other quality-related issues, policy leaders are going to need to take a role in convincing people with real-life examples that these ideas can work, noted Robert Blendon, MD, who runs polling programs at the Harvard School of Public Health.
They may want to take examples from other fields such as the use of generic prescription drugs where consumers had to be convinced that generics—even though they were cheaper—were for the most part as good as their more expensive counterpart medications. "We're going to need a lot of examples, and leaders are going to have to sound like they believe that [these actions] are good—that they're not just doing it to cut back on very sick people with care as a way of saving money," he said.
The public will need some more convincing before they say that their physician could be wrong—and a federal panel evaluating treatments is right.
"But that's what leadership is about over a long time—trying to bring people along," Blendon said.
The onset of swine flu has reignited the debate about whether retail-based, walk-in healthcare clinics are an appropriate venue for treating people with highly communicable diseases.
"Someone who is sick and goes into a retail setting is potentially putting all shoppers at risk," says James Milam, MD, a Vernon Hills, IL-based OB/GYN and president of the Illinois State Medical Society. "With a very communicable disease like this, people are being told to stay at home if they have a fever or a recent cough or those symptoms that are equated with swine flu. So, the last thing I would want if I were a shopper would be to have someone coming to get care at a clinic where I was doing my shopping."
William Briggs, president of the 36,000-member Emergency Nurses Association, raised similar reservations.
"Our concerns are that they have the adequate protections for staff and other clients when there is a flu epidemic,” Briggs says. "You’ve got to have the space to isolate them, to put a mask on, to have the right hand washing and disinfectants available, and that may not be present in a retail clinic.”
Briggs says it's also not clear if convenience care clinics are coordinating with local public health authorities to monitor the virus or send specimens to the state labs for confirmation. "To date, there is not a lot of regulation and oversight of these retail clinics,” he says.
Tine Hansen-Turton, executive director of the 1,250-member Convenience Care Association, dismisses Milam's concerns and says the retail-based clinics are proving to be "the first line of defense" in the effort to provide public access, diagnose the disease, answer questions, and allay concerns.
"We are a critical access point and we want to contribute like others to ensure that people are seen and taken care of," Hansen-Turton says. "We are there. We are in the community. We are close to where people live and we present a unique opportunity for people to get their concerns alleviated, and we provide a response to this healthcare threat."
Hansen-Turton says people with cold and flu symptoms already go to pharmacies for over-the-counter medications and advice, regardless of whether or not the pharmacy has a clinic. "They would have been there anyway because of their health needs, so we see this as an opportunity for them to be checked," she says.
Hansen-Turton says most, if not all, convenience care clinics have the ability to identify the Type A influenza with a nasal swab and provide a diagnosis within five minutes for patients who might otherwise have no access to a physicians office, or who can't afford an emergency room visit.
"We present an opportunity for people to be seen," she says.
Milam says the ISMS envisioned a scenario similar to the swine flu outbreak when it tried in February 2008 to get the Illinois General Assembly to pass a law requiring retail-based convenience clinics to have separate entrances, separate waiting areas for ill patients, separate bathrooms and sinks, and separate exhaust fans.
The bill failed, he says, because of pressure from the convenience care industry. "Our position hasn't changed," Milam says. "It seems counterintuitive to invite folks into a retail setting who have a very communicable disease," he says.
The Emergency Nurses Association and the American College of Emergency Physicians today issued a joint statement urging the use of a "prudent layperson standard" for people who suspect they may have swine flu.
"If you have symptoms that would not ordinarily take you to the emergency department but are considering going because you are afraid you have swine flu, you probably do not need to go," Briggs says. "Remember that many illnesses–not just swine flu–are transmitted in public places and very often the best way to avoid the spread of disease is to stay home until your symptoms subside."
For over a decade now, researchers have documented the effects of language barriers on healthcare, says Pauline W. Chen, MD, in this commentary for the New York Times. Patients who speak English poorly or not at all face longer hospital stays, an increased risk of misdiagnoses and medical errors, and decreased access to acute and preventive care services, often regardless of socioeconomic or insurance status, she notes. Chen says that according to a new study published in The Journal of General Internal Medicine, doctors’ assumptions about communication—what they deem important in a conversation—may also have a role.
Starting next year, Medicare coverage of hospice care will require physicians to write a "short narrative" describing the patient's clinical condition, under a proposed rule. The requirement, to take effect in fiscal year 2010, comes on top of a planned 1.1% cut in hospice care reimbursement rates, according to the proposed Hospice Wage Index rule announced by CMS. The agency said it was concerned about a rising number of hospice patients who survive longer than six months.
An international drug company made a hit list of doctors who had to be "neutralized" or discredited because they criticized the anti-arthritis drug the pharmaceutical giant produced. Staff at Merck & Co. emailed each other about the list of doctors who had been negative about the drug Vioxx or Merck and a recommended course of action. The email, which came out as part of a class action against the drug company, included the words "neutralize", "neutralized" or "discredit" against some of the doctors' names.
The housing market continues to make physician recruitment more difficult. And some organizations are increasing their signing bonuses to help with housing.
In the AMGA and Cejka Search 2008 Physician Retention Survey, 96% of respondents indicated they offer relocation assistance to physician recruits. Approximately 53% offer an average of $10,000–$15,000 to relocate a physician, while 26% spend within the range of $7,500–$9,900. The most common types of assistance were covering moving company and transportation expenses. It breaks down as follows:
Moving company expenses: 92%
Transportation expenses: 66%
Realtor fees: 10%
Other: 8%
Low-cost home loan: 6%
Housing subsidy: 4%
Other tactics under consideration include:
Temporary housing. Some organizations have bought houses (often at foreclosure prices) to provide temporary housing for newly recruited physicians who are trying to sell their houses.
Loans. Some facilities provide home loans to physicians. According to the AMGA/Cejka survey, about 6% do. What's more common—and more prudent—is for hospitals to coordinate with existing lenders. But this is all new territory and things may change depending on the economy, says Fredrick T. Horton, president and CEO of Horton, Smith & Associates in Overland Park, KS. He says he is seeing some systems help with bridge loan underwriting; it's still rare, but he expects to see more in the coming months.
Working with relocation companies. Some clients are referring the physician to relocation companies that may be able to assist in marketing the home. The practice is becoming increasingly common, Horton says.
One tactic that hasn't emerged is purchasing the physician's house, says William Scott Hurst, MBA, principal marketing consultant at Dallas-based Delta Physician Placement. When Hurst first looked into this issue last year, he heard "rumblings" about that approach. But organizations soon realized "it doesn't do them much good to buy a home in a different state," he says.
This article was adapted from one that originally ran in the April 2009 issue ofPhysician Compensation & Recruitment, a HealthLeaders Media publication.
The fallout from the market downturn in the last quarter of 2008 will have far-reaching effects this year, making 2009 a year of economic challenges. Practices must take appropriate measures to ensure continued success and growth while dealing with changes that are soon to come their way.
Strategic planning is usually perceived as a long-term view of practice operations. However, this year, strategic planning must be done by evaluating the basic administrative and billing procedures at the practice level.
Financial partners
When banks failed last year, credit dried up. Lines of credit that a medical office was able to tap into in the past for both short- and long-term needs may no longer be available. If a practice relied on these credit lines, administration must ensure they are still readily available for access if necessary. Make time to meet with the bank that services the practice to review the various accounts, especially if the institution has had a change in ownership. There may be a new banker assigned to the account who is unfamiliar with the needs of the practice.
The landscape of the insurance industry will also change drastically this year, and a practice must be prepared for the changes. In order to maintain or lower premium costs, many employers will be offering the medical or health savings accounts (HAS). These plans will be presented with a variety of names and acronyms to the general public, and the price will sound right. However, the public at large has a poor understanding of healthcare coverage, and a greater number of HSAs will pose an even greater problem. HSAs are coupled with high-deductible health plans, which place the financial risk on the patient and the provider. If the medical billing office is not educated concerning these plans, and proper verification is not performed, providers will be left with many thousands of dollars in unpaid patient accounts.
Point-of-service collections
Raising deductibles and copays/co-insurance represent another way to reduce premium costs for employers. A greater portion of the total cost of the service will be payable at the time of service, and not received from the insurance carrier. For example, if the cost of a service is $75 and the patient has a $50 copay, the insurance carrier responsibility is only $25. The bulk of the service will be paid from the copay. In-network deductibles will become more prevalent, so even if the practice is in the insurance network, the patient will still be responsible to pay his or her deductible. These amounts due need to be collected at the time of service for commercial carriers and submitted to the insurance companies in a timely fashion. Only then will the practice be compensated for future claims.
Tightening up the operations of the billing department, and creating a good working relationship between the front and back offices is critical.
Verification of medical insurance benefits must be performed prior to a patient visit. This information must be noted on the patient account for access by other staff members.
Copays, deductibles, and other patient monies due should be communicated to the patient at the time of appointment confirmation. If a patient has a past-due balance, this information should be relayed as well.
Money to be collected at the time of service should be communicated to the reception staff. This can be done through alerts in the software, written on charge tickets, or written on a printed patient schedule.
Reception staff should be given proper training on the appropriate method to request payment from a patient. If employees are hesitant to ask patients for money, they do not belong in that critical position.
When practice policy allows, copays and other amounts due should be collected prior to the service being rendered.
Patients should be offered all payment methods, cash, check, credit, and debit cards. Reception staff should be prepared to direct patients to the nearest automatic teller machine if necessary.
Patients with questions concerning billing should have access to a billing staff member either via telephone at the reception area, or preferably in person.
Administration needs to create tight financial controls as the money passing hands in the practice will be increasing. Expected monies versus actual over-the-counter collections should be monitored by employee to note any trends and discrepancies.
Billing department/company
The finances of a practice live (and die) in the operations of the billing department or billing vendor. Correct, compliant, and timely processing of claims will maintain a medical office through difficult financial times.
This year saw an enormous increase in the number of CPT and ICD-9 coding changes. If administration did not check their existing charge ticket against the new codes, the office may see a sharp increase in coding denials.
Explanation of benefits forms from insurance carriers are the best source of financial information for the practice. They need to evaluated line by line for codes, charges, receipts, and adjustments. Posting should be done carefully, with billers noting trends:
Are any carriers routinely downcoding claims?
Are reimbursements smaller than expected?
Is the timeframe for payment of claims longer than expected?
When was the last time (if ever) that the contracted fees were reviewed?
Utilize the financial reporting capabilities of your software to the maximum. Run your management reports (aging reports, productivity analyses, receipts and adjustments by carrier, days in receivable, system financial summary, patient breakdown). Compare the reports at regular intervals to look for trends and potential problems.
When using a billing vendor, insist on seeing the same reports as listed previously to ensure they are operating optimally.
Other areas of evaluation
Staff is the largest cost in a practice, so watch for task efficiency.
Are jobs overlapping, too may staff performing the same function, or not enough staff to operate efficiently?
Is everyone working to their maximum, or are there people who should be replaced with more efficient employees?
Are any long-time staff members making salaries that are "out of the ball park"? Consider other methods of compensation, including bonuses, instead of raising salaries.
Evaluate the vendors currently being used for such services as medical supplies. Many vendors had implemented "fuel surcharges" when the cost of gasoline was high, yet these charges should have been eliminated back in November.
Shop around for the needs of the practice, and negotiate with your vendors for the best prices and payment terms.
Take a hard look at provider productivity as well:
Are all of the providers working at an expected level?
Can an nonphysician practitioner be used to see additional patients?
Has a hospitalist been considered to better utilize physician office time?
Ask these questions regarding software:
Is the practice management system being utilized to its full potential?
Are software updates available that will allow automation of any function being performed by a staff member such as insurance verification and statement processing?
Steering a practice through a nationwide financial and healthcare crisis will take some savvy and hard work. Beginning with an evaluation of the basics and tightening the belt now will help to provide a safe financial future.
Schettino-Genrich is a consultant at Complete Management Solutions in Hauppauge, NY. Contact her via e-mail at sgenrich@cms-mgmt.com. This article originally appeared in the April 2009 issue of The Doctor's Office, a HealthLeaders Media publication.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
As Democratic leaders in Congress prepare to introduce healthcare reform legislation, the Obama administration is expressing concern about the growing primary care doctor shortage and exploring ways to increase physician supply, according to recent reports.
That is an encouraging sign. It shows that healthcare reform architects are paying attention to previous efforts in Massachusetts, where the promise of universal coverage has fizzled somewhat, in part because of a primary care shortage.
Without adequate primary care access, patients are showing up at emergency rooms and adding to overall costs—ED visits have risen 7% and the cost of emergency care has climbed 17% in Massachusetts in the past two years. That change may not all be linked to the newly insured, but it reveals the difficulty of providing universal coverage with limited resources.
Expanding coverage is only effective if there are enough physicians to treat the newly-insured population. Recognizing that truth is an important first step, but it is considerably easier than what follows: Figuring out how to increase the number of primary care doctors.
There are a number of viable options being considered. One would increase enrollment in medical schools and residency training programs. Another would encourage greater use of nurse practitioners and physician assistants. Officials are also considering deploying doctors and nurses in rural areas and poor neighborhoods, which are hit hardest by provider shortages.
While these are all necessary components of a multi-faceted solution, they don't get at one of the underlying causes of the primary care shortage: Money.
Simply put, primary care doesn't pay enough to lure many of today's medical students. When presented with the options of making $180,000 as a family practitioner and $400,000 or more as a proceduralist, students are increasingly choosing the latter.
The obvious solution to this problem is to somehow make primary care more rewarding. But proposals to increase primary care reimbursement are being met with resistance from specialists and surgeons who fear that the increases will come at the expense of their own compensation.
Peter J. Mandell, a spokesman for the American Association of Orthopaedic Surgeons, summed it up in the New York Times: "We have no problem with financial incentives for primary care. We do have a problem with doing it in a budget-neutral way. If there's less money for hip and knee replacements, fewer of them will be done for people who need them."
This "class warfare" between physicians has popped up before, and it will probably only get more intense as the healthcare reform discussion continues.
The inter-specialty squabbling reminds me of Garrett Hardin's classic essay about "The Tragedy of the Commons." Hardin described the conflict that often arises when individuals acting in self-interest ultimately destroy a shared limited resource.
He used as a metaphor a common grazing area shared by a group of herders. There is an optimal number of cows for each herder to allow onto the common field so that the full benefits are reaped without overgrazing the pasture. But each individual herder has an incentive to add more cattle, because he receives the full benefit while the costs—the damage done to the common—are shared by the entire group. Herders instinctively add more cattle to the field until they exceed the optimal grazing level. Eventually, the entire field is destroyed, though a few of the more aggressive herders benefit in the process.
Physicians face a similar dilemma. The pool of dollars for reimbursing physicians for Medicare and Medicaid is limited. And while the payment disparity has benefited certain surgeons and specialists, the damage caused by a lack of primary care physicians affects the entire healthcare system.
Reforming the healthcare system can only be done through some very hard choices. Increasing payment to primary care at the expense of some of the higher-paid specialists may be one of those.
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A recent ruling by the Tennessee Court of Appeals may leave the door open for a new interpretation of peer review protection legislation. The court ruled that hospitals—not just physicians—can be granted immunity in cases of physician negligence as long as the peer review decision was reached in good faith.
"This case strictly focuses on a Tennessee statute and the court recognized the constraints inherent in that statutory language. However, the premise of a peer review process is to objectively evaluate the conduct of a professional and make informed judgments," says Bruce D. Armon, Esq., attorney with Saul Ewing LLP in Philadelphia.
In most states, peer review laws provide confidentiality and legal immunity to those who participate in peer review—usually medical professionals who raise concerns about a colleague's ability to competently practice medicine or provide testimony during a peer review case.
"The idea is that protection will encourage better review," says Alice G. Gosfield, Esq., attorney with Alice G. Gosfield and Associates in Philadelphia.
In the case, the plaintiff, a patient, sued both a plastic surgeon practicing at Centennial Medical Center for malpractice and the hospital itself for negligent credentialing, claiming that the hospital should have revoked the physician's privileges because of a lack of competence.
In an appeal, the plaintiff asserts that Tennessee's statute regarding peer review is unconstitutional and argues that granting the hospital immunity when a patient sues over a credentialing decision is inconsistent with the original intent of the statute, which is to protect and encourage healthcare workers to participate in the peer review process.
At the center of the appeals case was the issue of interpreting the statute to determine whether hospitals are covered under qualified immunity when a patient sues. "The Tennessee statute is not a model of clarity," Gosfield says, adding that most peer review statutes are similarly unclear.
The split decision was written by Tennessee's Court of Appeals Judge Andy D. Bennett, who stated, "We hold that the qualified immunity defense under [the peer review protection law] is available when a patient sues a hospital for credentialing decisions made by a peer review committee." It also ruled that the statute is constitutional.
The concurring opinion recognizes the need to gather relevant facts to determine culpability for a hospital's peer review committee, and the decision underscores the importance of the peer review process, Armon explains.
However, the court did not hold that Centennial Medical Center was specifically immune. The case has been remanded back to the trial court to determine whether Centennial's credentialing decision was made in good faith.
According to Gosfield, the court is saying that the hospital itself cannot be liable unless the peer review was conducted with malice and not in good faith. "It's really a sideways view of peer review protection, and not really what the statutes were supposed to be about," she adds.
One week after holding a hearing on reforming the healthcare delivery system, members of the Senate Finance Committee met behind closed doors on Wednesday in a "walk through" session to examine options on paying for and delivering healthcare.
Many of the options brought up at the earlier hearing—addressing issues such as chronic care management, quality measure development, provider collaboration, health information technology, and workforce strategies—are found in the committee's new 52-page report. Providers, along with the public, can comment on the options through May 15.
The walk through—essentially examining a draft of ideas—is the first of three expected from the committee as it looks for ways to address healthcare reform and care delivery. "But nothing is set in stone," Baucus said on issuing the report. "The policy options ...put some meat on the bones of those ideas to strengthen our discussion moving forward."
Among the areas that providers would find of interest are:
Establishing a hospital value-based program. Looking at Medicare's Hospital Quality Data for Annual Payment Update program (also referred to as the hospital pay-for-reporting program), the committee is examine a value-based purchasing program that goes beyond paying for reporting on quality measures and activities; instead, payment would be based on hospitals' actual performance with these measures.
Primary care and surgery bonus. Physicians could receive bonuses over fee schedule amounts by demonstrating "quality achievements," using electronic prescribing or working in underserved areas. Providers who furnish at least 60% of their services in ambulatory settings could receive bonuses of at least 5% for evaluation and management services related to office visits, nursing home visits, and home visits; these services could be provided to both new and established patients.
Readmission. The committee is looking at ways to reduce "avoidable and preventable" hospital readmissions while using payment incentives to encourage greater care coordination. Under this option, Medicare in 2010 would begin to identify national and hospital-specific data for readmission rates related to eight conditions (selected because of their high volume and the high rates of readmission). Hospitals later would be informed about how their readmission rate compares nationally, and could receive a payment withhold if they do not improve.
Bundled payments. Also being eyed are bundled payments for hospitals and post-acute care services (such as home health or skilled nursing facilities) following discharge from a hospital during a period of up to 30 days.
Health information technology. Options include encouraging widespread adoption and meaningful use of health information technology by extending Medicare health IT incentives to other providers not included in the American Recovery and Reinvestment Act passed in March.
Healthcare workforce. To promote a sufficient supply of healthcare professionals for the future, the policy options under consideration look at increasing graduate medical education training positions for primary care.
Comparative effectiveness research. The committee said it would consider options to create long-term or permanent framework for setting national priorities for comparative clinical effectiveness research.
