In response to news reports of unusually high wholesale price increases in brand-name prescription drugs, Democrats in Congress asked for two separate investigations of drug industry pricing as they continue working on legislation to overhaul the nation's healthcare system. Although drug makers challenge the theory, some experts say the run-up in wholesale prices may be partly related to the industry's concerns about future cost containment under any healthcare legislation, the New York Times reports.
Medicare beneficiaries would pay $49 billion in higher Part B premiums between 2011 and 2019 under a bill (HR 3961) the House will consider Thursday that raises fees for physicians treating Medicare patients, according to Congressional Budget Office (CBO) estimates.
The bill, a companion to the healthcare reform bill (HR 3962) passed earlier this month by the House, calls for repealing the 21% fee reduction under the current sustainable growth rate (SGR) formula scheduled for January 2010. CBO said that enacting the bill would increase direct spending by about $210 billion over the next decade, but it would not affect federal revenues.
The changes to the SGR formula would increase the fees paid to physicians under Medicare by about $195 billion over the 10 year budget projection window, CBO said. The changes to the formula would also result in higher spending for both the Medicare Advantage (MA) program and the Department of Defense's TRICARE program, which uses Medicare's physician fee schedule to pay for physicians' services.
CBO estimates that changes under the bill would total about $64 billion over the budget window. The MA spending would rise because the benchmarks that Medicare uses to determine how much the program pays for those enrollees "are adjusted for changes in Medicare spending per beneficiary in the fee for service sector," CBO said. The benchmarks have been set for 2010 and will not be changed, so there would be no impact on MA spending until 2011.
In a joint letter to House Speaker Nancy Pelosi (D-CA), American Medical Association Executive Vice President Michael Maves and AARP CEO Barry Rand wrote that those "who are concerned about deficit spending must recognize that the past practice of 'temporary Band aids' on the SGR problem has only served to increase both the size of future cuts and the cost of subsequent interventions."
Under HR 3961, the SGR would be replaced with a new formula that:
Removes items, such as drugs and laboratory services not paid directly to practitioners from spending targets
Allows the volume of most services to grow at the rate of the gross domestic product (GDP) plus 1 percentage point per year (compared to GDP without any adjustment today)
Allows the volume of primary and preventive care services to grow at GDP plus 2% per year
Encourages coordinated care by allowing accountable care organizations to be responsible for their own growth paths, irrespective of reductions or increases that apply elsewhere in the system
Last month, in a 53-47 vote, the Senate turned down efforts to repeal SGR formula as proposed in a bill introduced by Sen. Debbie Stabenow (D-MI). Forty Republicans and 13 Democrats voted against the motion.
The northern part of California, western Nevada, and southern Oregon now have a hospital that can implant "destination" heart pumps for patients who, because of other conditions or diseases, aren't eligible for a heart transplant.
With the certification granted by the Joint Commission last month, Sutter Medical Center in Sacramento became one of five hospitals in California to be certified, the only way the facility is eligible for federal reimbursement for the procedure.
Medicare's base payment for the device to Sutter is $140,512 per unit. And on average, according to a Medicare spokeswoman, the payment is $135,523.
At the same time, the 306-bed Sutter also regained approval to revive its heart transplant program, which had been discontinued by the Centers for Medicare and Medicaid Services because it did not meet the minimum number of transplants now required by Medicare.
The pumps, called ventricular assist devices or VADs, are usually used only for congestive heart failure patients as a bridge to recovery after heart surgery, or as a bridge to transplant while they are wait-listed with the United Network for Organ Sharing for a suitable donor heart.
With destination VAD implantation, many patients who are too sick for a heart transplant can benefit from a longer, better quality of life. The device enables most to live independently, away from a hospital bed. Without the device, their health continues to painfully worsen, with many expensive readmissions back to the hospital.
"They'd die in the hospital, or at home on hospice," says Kelley Jaeger-Jackson, Sutter's nursing director for transplant and ventricular assist device program.
But with implantation of destination therapy devices, instead of staying in the hospital waiting for a heart, they can be discharged home with the devices implanted and live relatively normally.
So far, Thoratec, which makes the one device that has received FDA approval for destination therapy so far, the HeartMate XVE, has a 72% survival rate for those who have lived with the implantation for 18 months.
Unless a facility was involved in a clinical trial of one of the pumps now being tested, they could not get reimbursed without Joint Commission certification.
The number of hospitals nationally seeking destination VAD certification is growing rapidly, says Caroline Isbey, associate director for the commission's disease specific certification.
So far, most hospitals receiving that also have the capability of performing heart transplants. But more hospitals that are not transplant centers are applying for certification as well. "We have eight applications submitted this year, which will bring us close to 80 by the end of the year or the first quarter of next year," Isbey says.
The commission requires certification of destination therapy procedures because it needs to verify that a facility's cardiac surgeon, who will perform the procedure, has enough experience implanting VADS; that the hospital keeps the appropriate registry; and maintains sufficient program quality reviews, she says.
So far, not many VADs have been implanted as destination devices. Jaeger-Jackson says the largest centers have only done about 40. But a decision by the U.S. Food and Drug Administration to approve a newer device, also by Thoratec called HeartMate II, is expected by year's end, Jaeger-Jackson says.
If and when it is approved, more patients can be implanted with the newer device, she says.
That's because the current destination pumps, HeartMate XVEs, are shaped like a hockey puck—about three to four inches in diameter, and weigh about three to five pounds, and aren't appropriate for smaller-sized individuals.
In contrast, the HeartMate II is much smaller, about the size of a yogurt cup. It weighs less, and may be more durable because it has fewer touching parts, Jaeger-Jackson says. According to Sutter Transplant Services VAD Coordinator Sherry Martin, the HeartMate II could last five to 10 years.
In San Diego, Sharp Memorial Hospital (http://www.sharp.com/) is the only hospital south of Los Angeles to implant destination heart pumps and was among the original investigating centers for first HeartMate XVE, says Suzanne Chillcott, who leads the mechanical circulatory support team.
The hospital has now done at least 35 implants, and has sent people "home to get on with their lives, instead of home to die." In some cases, she says, patients have done so well, their diseases and organ failure issues have resolved and they're now well enough to be put on a transplant list for a real heart.
"This is definitely a very big growth area for hospitals," Chillcott says. "I believe there will be many more centers wanting to get involved in doing these."
According to the American Heart Association, an estimated 5 million Americans have congestive heart failure and 250,000 people in the U.S. die from it a year. More than a half a million new cases are diagnosed each year. The five-year average mortality rate is 50%.
Incident rates mortality and hospitalizations related to heart failure continue to rise. The AHA estimates that 34.8 billion was spent in direct and indirect costs on heart failure last year.
While the theatrics of the reform debate hold the nation in suspense, another dramatic policy change—with potentially tragic ramifications—has crept into next year's Medicare physician pay schedule with astonishingly little fanfare.
But specialty providers who are now becoming aware of the plan say it will have dire consequences for care far into the future, especially for rural communities where specialty doctors are in heavy demand.
"When these doctors find out about this, they are going to go ballistic," says Larry deGhetaldi, MD, administrator of the Palo Alto Medical Foundation, a multi-specialty group practice with 900 physicians in Santa Cruz, CA.
He adds that if it weren't for the complexity and anxiety over health reform, "this would have been the major freak-out issue."
As of Jan. 1, the Centers for Medicare and Medicaid Services plans to eliminate a series of five-digit CPT codes that specialist physicians, such as cardiologists, oncologists, and surgeons, use to bill for medical or surgical consults. These consults occur at the request of a practitioner who wants a specialist's opinion regarding his or her patient.
For example, an internist may want his patient seen by a vascular surgeon. Or a family practitioner may want her patient seen by an endocrinologist or pulmonologist.
Under current CMS rules, the CPT code for consultation calls for reimbursement that is between $20 and $50 higher than for a comparable office visit.
But by eliminating the CPT codes, those specialists will be forced to bill under a different payment code bracket, which covers for a simple office visit.
The rule change could have an impact on some specialists' willingness to be available for specialty referral care, either in the hospital or in their office practices, says Ted Mazer, MD, a San Diego area otolaryngologist.
"The potential impact on already endangered ER call panels should have been considered as well. The devaluation of the consultants' services may adversely impact access in both city and rural settings," Mazer says, especially in areas where there is already a shortage of some specialists.
Consultation services are important and time consuming, Mazer explains.
First, the patient's condition must have added complexity or it wouldn't have needed referral.
Second, the specialist performs an independent physical and often gets a separate history of the patient, spending as much as an hour to set a correct diagnosis and course of care. And third, reimbursement policy requires the specialist physician to return to the referring physician a written report of the findings and course of care in the outpatient setting.
All of that takes time and expertise, argues Mazer, who says the specialists' skill and knowledge should be appropriately compensated.
When this change takes effect, he worries that the confusion in what codes Medicare will accept and delays in payment will result in cash flow problems for specialty physicians as well, he says.
The policy change has come about in part because of a desire on the part of the Obama Administration to increase reimbursement to primary care physicians, who are increasingly in short supply. But such redistribution may tend to worsen the schism between those groups and specialists.
But it also has come about because of overutilization, seen by maps that show many areas of the country use specialty consultations far more than in others, deGhetaldi says.
"Patients in certain parts of the country who undergo a routine hospital admission will have 10 consults," deGhetaldi says. "If they force this new patient code, that will control some of these costs."
Physicians acknowledge that overutilization of consultants is largely to blame for the change. And that belief was documented last week by a report in the Archives of Internal Medicine study "Is It Time to Eliminate Consultation Codes?" by Joel I. Shalowitz, MD, of the Kellogg School of Management at Northwestern University in Evanston, IL.
Shalowitz reviewed 500 claims for consultation services over a 13-month period ending this July and discovered 32.4% were in error. The report concluded that changing ambulatory consultation codes to those for new patient visits would save Medicare $534.5 million per year.
"With the growing needs for cost savings as well as encouraging payment parity for cognitive services for primary care physicians, it is time these codes are reevaluated," Shalowitz wrote.
Mazer, however, says that's not the right answer to the problem. "Do we throw away an entire system of coding rather than address the educational needs for proper use of the codes?" he asks.
"There is legitimate value in consults, which often require a higher level of expertise for a more complex problem, which is why the consult was requested to begin with," Mazer says.
The American Medical Association has written CMS expressing its objections, especially about the speed at which the change seems to have been pushed into place. "While there may be advantages and disadvantages to this proposal, the AMA has strong concerns about moving forward with the consultation code proposal on Jan. 1, 2010," according to a letter from AMA Executive Vice President and CEO Michael Maves, MD.
"It would be impossible to educate all physicians who currently report consultation codes in such a short period of time, which means there would be a flood of claim denials and appeals," he wrote.
"Further, at a time when the President and Congress are seeking administrative simplification as part of healthcare reform, this new policy would undermine this goal by setting up different standards for Medicare versus other payers that will still be using consultation codes."
The California Medical Association is drafting a similar letter of objection.
Ned Bentley, MD, a Northern California gastroenterologist, also had harsh words for the policy change. Eliminating these codes, "threatens to undermine the CPT Editorial Panel process and a well-established system to describe and report physician work," he wrote in a briefing paper.
However, AMA officials say they expect the pay change is, regrettably, final, and fear that physicians will be overwhelmed with fighting denials when they unknowingly turn in old CPT codes for reimbursement.
"While policymakers are looking for ways to improve coordination of care, it seems counter-intuitive that CMS would move forward with this proposal without understanding the implications for the impact on care coordination," Maves wrote.
Editor's note: This is the third in a three-part series about breach notifications. Part one focused on how to prevent breaches. Part two tackled how to handle breaches. This installment offers some final tips if a breach occurs.
Now that you've followed protocol—the government's and your facility's—consider these final checklist items for after you respond accordingly to a breach.
They are offered by Andrew E. Blustein, Esq., partner and cochair of Garfunkel, Wild & Travis' Health Information and Technology Group in Great Neck, NY; Hackensack, NJ; and Stamford, CT:
Incorporate lessons learned into existing procedures (were internal reporting and investigation fast and efficient?)
Include the breach on the annual log reported to HHS
Modify policies as necessary
Reeducate staff members regarding lessons learned
Look for repeating patterns (e.g., one patient area that has multiple incidents)
Include the unauthorized disclosure on the accounting of disclosures
Include any sanctions on the HIPAA sanctions log
Ensure that investigation notes and reports were appropriately detailed and that they are maintained
HHS has said it will not enforce breach notification provisions until February 2010—or 180 days from the publication of the interim final rule—but HITECH states that covered entities (CE) are subject now to penalties for noncompliance.
CEs should have breach response systems in place already, says Chris Simons, RHIA, director of UM and HIM and the privacy officer at Spring Harbor Hospital in Westbrook, ME.
However, if CEs still need to work on their policies, they should focus their energies on making sure staff members understand the process for and importance of prompt reporting.
"If your staff doesn't know who their privacy officer is, that's a problem," Simons says. "That's a good starting place. Make sure staff knows what a breach is and who to report it to. They should be encouraged to immediately report even the suspicion of an issue."
Document everything your organization does in response to a suspected breach, Simons adds. Conduct a risk analysis to expose your internal weaknesses. It could help you prevent a breach in the first place, which, after all, is the goal.
"What are your serious risks, and what are your minor risks?" Simons says. "How are you educating people, and are your policies and procedures in place? Get out there and do your rounds to see what's going on and see if you hear things."
Total OSHA fines and inspections decreased across all types of healthcare facilities in FY 2009.
Medical and dental practices and hospitals saw the greatest decreases in fines, 30%-40% from the previous year, according to OSHA's Statistics and Data Web page. Nursing care facilities and laboratories showed less dramatic decreases at 12%-14%.
Nursing facilities ($321,327) and hospital settings ($196,400) ranked first and second respectively in total fines by type of facility, accounting for nearly three-quarters of OSHA fines issued in healthcare. Next came medical ($52,214) and dental ($47,549) practices at approximately 7% each of total OSHA healthcare fines.
Even though this is the second straight year healthcare violations have seen a decline, the trend is not likely to continue. OSHA under President Obama has an increased budget, including 130 new inspectors, according to remarks made earlier this summer by acting Assistant Secretary of Labor for Occupational Safety and Health Jordan Barab to the American Society of Safety Engineers. "The law says that employers are responsible for workplace safety and health, and there's a new sheriff in town to enforce the law," said Barab.
In addition to more enforcers, there is also better ammunition. OSHA officially posted its revised field operations manual (FOM) last week and the consensus of opinion among safety professionals is that the FOM gives inspectors more latitude in issuing violations, especially in the areas of defining recognizable hazards with regard to the general duty clause, focusing on hazard assessments, and providing more guidance on issuing willful violations.
Also in effect this year is a new recordkeeping national emphasis program (NEP) to find employers who are underreporting injuries and illness in traditionally high-hazard work settings. Nursing care facilities are included in the scope of the NEP.
Finally there are some issues on the legislative horizon pointing particularly to healthcare. A survey by the Association of Occupational Health Professionals in Healthcare found that healthcare workers were most concerned about bloodborne infections from needles, injuries for handing and lifting patients, and protection from airborne diseases. While the bloodborne pathogens standard has been on the books for awhile—indeed this hazard continues as the leading source for violations in all healthcare settings—there is movement for federal standards on the other two.
Both the House and the Senate have bills calling for OSHA to produce a safe patient handling and lifting standard.
Meanwhile, this fall, California introduced an aerosol transmissible disease standard that required employers to provide protection from hazards, such as tuberculosis, SARS, and pandemic influenza.
With the full effect of H1N1 on the healthcare workface yet to be assessed, and given California's position as the bellwether for federal OSHA standards—it led the way for the eventual bloodborne pathogens standard in 1991—it seems likely that healthcare will be facing additional compliance matters in the next few years with potential for increases in citations and fines.
"My name is Hiram B. Pressure, but you can call me HBP," says the American Heart Association's newest spokesman—a cartoon purple heart who sports thinning hair, white socks, and Birkenstocks. "And you can call me later, sweetheart. Hey-o!"
The American Heart Association created the rude and crude Hiram, who personifies high blood pressure, to educate the public about how lifestyle choices affect their health, all while keeping a comedic tone. Hiram is featured in an online video where he annoys restaurant goers with his obnoxious habits, such as excessive drinking, smoking, and eating a triple-decker burger topped with a mountain of salt.
"We've put a funny spin on the serious subject of high blood pressure," said David Meyerson, MD, director of cardiology consultation services at Johns Hopkins Bayview Medical Center and national high blood pressure spokesperson for the American Heart Association in a press release.
The video lives on the American Heart Association's new high blood pressure Web site, which includes information on related diseases and conditions, prevention, diagnosis, and treatment. Keeping with the jovial tone of the cartoon, the site also contains quizzes and animation.
"On the Web site, we've cut the medical jargon to let humor and technology help us reach both old and new audiences," Meyerson said. "Our goal is to use new tools, such as social media, to open the door for conversations about the condition among the one out of three Americans who have high blood pressure."
Hiram is also featured on a Facebook fan page called "HBP Escapees," which includes high blood pressure information and a video detailing the proper way to monitor blood pressure at home. HBP Escapees had 107 fans at press time.
Top healthcare executives say patient experience is among their top priorities, but are they looking toward marketers to drive the effort? Not according to the 2009 HealthLeaders Media Patient Experience Leadership Survey, released online this week.
HealthLeaders Media surveyed more than 200 top-level healthcare executives about their organization's patient experience efforts. One of the questions we asked: "In your executive suite, who 'owns' the primary responsibility for patient experience?"
The top answers were "CEO" (24.5%), "no one specific individual" (20.5%), and "other" (18.5%). Among the "other" answers, a good chunk of the respondents wrote in "everybody."
As if that weren't enough to mull over, the number of CEOs who said their chief marketing officer or chief experience officer was responsible for patient experience was a measly 2%, split evenly between the two titles.
They came in last, not only behind CEOs, everybody, and nobody but also behind chief nursing officers (16%), chief operating officers (10.5%), chief quality officer (5%) and chief medical officer (3%).
(What do you think? Who should be responsible for the patient experience? Take our quick poll and let us know what you think.)
Now I understand there's been a call for patient experience to be more of a strategic effort. There are many out there who say it is not a function of marketing. And there are others who say that marketers should step up and take charge of this important initiative.
It doesn't matter who's right about that. The bottom line is that CEOs are sending a couple of messages loud and clear.
For starters, the fact that CEOs put themselves first is encouraging. It says to me that they're taking responsibility and it backs up the survey findings that say it's either their top priority (33.5%) or among their top five priorities (54.5%). But just because a CEO takes responsibility for the success or failure of an initiative it doesn't mean he or she is the one doing the work.
And that's the second message: That CEOs don't see marketers as being capable of doing that work.
Gary Adamson, chief experience officer of Starizon, an experience design consultancy in Keystone, CO, agrees the numbers are indicative of how CEOs view marketers.
"Experience staging is operational. You have to do things differently in the way you operate," he says. "I imagine the reason that number is so low is that healthcare leaders by and large don't view marketing as an operational function, they view it as a communications function."
Marketers didn't just rank low in the survey—they came in dead last. Chief marketing officers ranked behind chief medical officers, for goodness' sake. That means CEOs are looking to physicians rather than a marketers to make sure patients have not just good clinical outcomes but a positive experience. Physicians, who are often recognized as one of the biggest stumbling blocks to improving the patient experience. Does that sound logical to you?
Note: You can sign up to receive HealthLeaders Media Marketing, a free weekly e-newsletter that will guide you through the complex and constantly-changing field of healthcare marketing.
"Traditional" search engine marketing involves engaging end users who are searching with intent, and these are patients that are actively on the path to purchase healthcare from your physicians and hospital, writes healthcare marketing consultant Chris Boyer. These patients use search engines to discover authoritative content and target their searches to specifically find healthcare to best suit their needs, Boyer adds. Here, Boyer provides three simple tips to implement in your online marketing strategy to best capture these users.
