Massachusetts medical device companies continue to battle a proposed federal tax on device makers as lawmakers work to reconcile differences in the House and Senate versions of national healthcare overhaul legislation, the Boston Globe reports. The bill reported out of the Senate Finance Committee would raise $40 billion over 10 years from a tax based on the revenue of device manufacturers, and the bill approved by the House last weekend would raise about $20 billion from a 2.5% tax on a broader class of medical equipment. Device companies are pressing for an amendment that would eliminate the tax from the Senate legislation.
Atrius Health, a Newton, MA-based alliance of five community medical groups across Eastern Massachusetts, announced it is expanding its ties with Beth Israel Deaconess Medical Center in Boston in an effort to control costs while maintaining quality. Under the deal, approved by the boards of both organizations, Atrius plans to broaden its collaboration with Beth Israel in ensuring hospital care for cardiovascular and oncology patients as well as others with complex needs.
The Democratic party's liberal wing is trying to force a retreat from a deal struck in the House to ensure that federal funds aren't used for abortions under a healthcare overhaul. The House, in the final stages of debate over its version of health legislation, passed an amendment authored by Michigan Democratic Rep. Bart Stupak that blocked abortions—except in cases of rape, incest or a threat to the life of the mother—from being covered by a government-run health-insurance plan, or by any insurance plans bought with the help of government subsidies. The move has created a divide in the health reform debate, the Wall Street Journal reports.
Senate Majority Leader Harry Reid is considering a proposal to increase the Medicare payroll tax on high-income workers to help offset the costs of providing health insurance to millions of Americans. The proposal is part of a legislative package that Reid has put together in secrecy and submitted to the Congressional Budget Office for analysis, the New York Times reports. The Medicare payroll tax is the primary source of financing for Medicare's hospital insurance trust fund, which pays hospital bills for beneficiaries, who are 65 and older or disabled.
The Joint Commission has announced two changes to its Preliminary Denial of Accreditation (PDA) decision— the elimination of one rule and revision of another.
Rule PDA06, which addresses the need to have a license, certificate, or permit, has been altered.
Previously, if an organization was found to lack certain specific licenses, certificates, or permits at the time of survey, the organization would receive a PDA decision. This lack of license or permit often was the result of the organization being unaware such a permit was needed, and would result in immediately obtaining the permit (or, if the permit application is already in process, demonstrating during the survey that steps to apply for the permit have been taken).
Under this change, however, the organization lacking the license must now show an acceptable Evidence of Standard Compliance demonstrating that the organization has received the necessary license, certificate, or permit—until that time the organization receives an accreditation decision pending receipt of this documentation and receive a Requirement for Improvement (RFI).
In order to assure The Joint Commission that appropriate processes or policies are in place for obtaining this license or permit (and thus it will be renewed in the future in a timely manner), the RFI will remain in the survey report.
Additionally, the accreditation organization has completely eliminated rule PDA07, which was invoked after a healthcare organization received a Preliminary Denial decision on two consecutive full surveys.
Performance measurement update
In other Joint Commission news, the organization will introduce a new set of Perinatal Care core measures on April 1, 2010. This new set will be in addition to existing measure sets hospitals can use to fulfill ORYX reporting requirements.
The new Perinatal Care set replaces "Pregnancy and Related Conditions," which will be retired March 1, 2010. The measure set will include the following:
Elective deliveries
Cesarean sections
Antenatal steroids
Healthcare associated bloodstream infections in newborns
Exclusive breast milk feeding
As before, the choice of measure sets is up to the hospital, depending upon appropriate services provided as well as patient population data.
This week's mixed-bag news item comes from a study that found primary care physicians have been spending more time—and not less, as anticipated—with their adult patients compared to a decade ago.
That's good news for patients—and very surprising in light of the reimbursement system that pays primary care physicians proportionately less than other physicians.
However, the corresponding gains made in quality improvement remained sometimes modest, or even flat, for many of those physicians.
Previous studies have suggested that "significant investments of primary care physician time" may be required to deliver high quality care, said researcher Lena Chen, MD, of the University of Michigan Health System in Ann Arbor, in the study that appears this week in the Archives of Internal Medicine.
So Chen and her colleagues went out to find whether "efforts to improve efficiency" might have a detrimental effect on quality of care at the visit level. They started by conducting a retrospective analysis of visits by adults 18 years or older to a nationally representative sample of office based primary care physicians in the U.S.
What they found was that between 1997 and 2005, adult primary care visits in the US increased from 273 million to 338 million annually—or 10% on a per capita basis. At the same time, the mean visit duration increased from 18.0 to 20.8 minutes.
Visit durations increased by 3.4 minutes for general medical examinations and for the three most common primary diagnoses of diabetes mellitus (4.2 minutes), essential hypertension (3.7 minutes), and arthropathies (5.9 minutes). Comparing the early period (1997 2001) with the late period (2002 2005), quality of care appeared to improve for one of three counseling or screening indicators and for four of six medication indicators.
Providing appropriate counseling or screening generally took 2.6 minutes for diet, 2.7 minutes for blood pressure check, and 4.2 minutes for exercise counseling. Providing appropriate medication therapy, however, was not associated with longer visit duration.
On average, visits with general internists were 1.7 minutes longer than those visits with family or general practitioners. Other characteristics, though, such as practice location in a metropolitan area and physician ownership of the practice, were not associated with differences in duration.
Overall, in regard to patient factors, older patients had longer visits—18.4 minutes for those 76 or older—compared with 16.7 minutes for those ages 18 to 35.
The findings suggest that the relationship between visit duration and quality of care depend on the type of quality indicator.
Overall performance on clinical quality metrics was poor. Better performance on medication quality measures did not seem to require extra physician time, while better performance on counseling or screening indicators was associated with longer visit duration.
"Improvements in quality of care will likely require a combination of investments in systems, such as electronic health records, greater use of other professionals, such as nurse practitioners, and better reimbursement to primary care physicians for the extra time spent," they concluded.
Note: You can sign up to receiveQualityLeaders, a free weekly e-newsletter that provides strategic information on the business of healthcare management from around the globe.
Healthcare providers in several states received their first RAC denials.
Connolly Healthcare, the Region C RAC for Florida, South Carolina, and several other states, has been behind many of them.
One hospital in South Carolina reports having three claims denied. However, learning of those denials did not go smoothly. The hospital received a call in late October from Connolly regarding a denial letter the hospital said it didn't receive. The RAC sent the original denial letter in early August, and although it was addressed to the hospital, it reportedly had no specific contact person listed, and the hospital never received it, according to the hospital.
The hospital said it had provided Connolly with the name of the contact person for their facility months prior through the form Connolly provided on its Web site, according to a hospital employee.
"Connolly acknowledged that the absence of a contact person on the letter was their error and they are working to correct it," she said.
In the meantime, the RAC has faxed a copy of the denial letter to the hospital. The total take back was less than $200, but it has given the hospital a chance to test its RAC tracking system, which is reportedly working well thus far.
Another small contract rehab company that contracts with facilities across seven states, mainly in the southeast, also reported seeing RAC denials. Three of its facilities, all skilled nursing facilities, averaging 120 beds, have now received demand letters, according to the Florida-based provider.
"A majority of what we are seeing is recoupment of service-based codes billed in error more than once per day, mainly speech therapy (ST) service-based codes," according to the provider. "We have also received two that included recoupment for the ST codes of 92610 and 92526 billed on the same day, which we have disputed and reported this issue to the American Speech-Language-Hearing Association."
The provider is appealing the denials where the RAC is seeking recoupment of the ST codes 92610 and 92526 billed on the same day.
"We have a dedicated denials and appeals department and we have been handling these very efficiently and effectively," the provider said. The provider has had no problems so far with the appeals they have submitted.
The provider also noticed that the demand letters seem to be taking approximately two weeks to arrive, so timing is of the essence, particularly if the provider is going to respond with appeals.
The provider adds that it has used the denials as a guide for its internal auditing. Staff members are now going back to look for trends or patterns related to those denials.
The American Hospital Association released a report today that questioned studies that link geographic variation in healthcare spending to skyrocketing health costs.
The report, Geographic Variation in Health Care Spending: A Closer Look, charged that regional spending data, such as information from the Dartmouth Atlas, don't tell the full story.
"Greater exploration of the factors influencing variation is warranted before such estimates—or policies in response—can reasonably be made," according to the report.
The AHA questioned the Dartmouth Atlas' stance that higher spending does not equal higher healthcare quality. AHA wrote the Dartmouth Atlas' analysis of per-beneficiary Medicare spending across regions are often cited by policymakers, but health costs are driven by factors not addressed by the Atlas, including the number of uninsured and number of people with chronic disease.
AHA warned policymakers must be aware of the multiple reasons for a region's health costs.
"Crafting policies that hold the appropriate stakeholders accountable but avoid a one-size-fits-all strategy will be important to avoiding unintended consequences for patients and communities while improving the long-term financial stability of the U.S. healthcare system. Payment policies could address variation via payment rates, but so could public health strategies to reduce obesity or the burden of chronic conditions by targeting the underlying drivers of variation.
"Given conflicting research and local examples that contradict the hypothesized national trend, conclusions about connections between spending and quality would be premature," wrote AHA. "Understanding the value of healthcare spending for different patients and clinical scenarios is pivotal to identifying what level of spending is appropriate."
The American Medical Association has voted to oppose the military's "don't ask, don't tell" policy, and declared that gay marriage bans contribute to health disparities based on evidence showing that married couples are more likely to have health insurance. The AMA is also urging the government to consider reclassifying marijuana from a Schedule I controlled substance in order to clear the way for clinical research and alternative ways to deliver the drug.
On June 23, CMS sponsored an ICD-10 conference call for physician specialty group representatives. The CMS presentation included the following 12 steps for group practice ICD-10 implementation:
1. Organize the implementation effort. This includes establishing a point person to oversee the conversion. Choose someone who is familiar with the departments that the code changes will most heavily affect. Include coders, information systems, billing, managed care contracting, and physicians in the development of your implementation plan.
2. Establish a communication plan to keep everyone up to date on the progress. Communicate with stakeholders on a monthly basis until six months prior to implementation, at which point you should communicate biweekly, according to the CMS presentation. Determine which method of communication is most appropriate for each team player. For example, some staff members may not respond to e-mails or memos and may benefit instead from short meetings with verbal updates.
3. Conduct an impact analysis, which includes a budget for system updates, staff member training, and coding resources. Don't forget to include the additional staff member time needed for the conversion.
4. Contact system vendors to ensure that they are ready for implementation well in advance of October 1, 2013. Physician practices should already be talking with vendors about compliance with the new HIPAA 5010 transaction standard. All covered entities must comply with this new standard by January 1, 2012. Ask your vendor when it will be ready to test the systems. One vendor explained that it cannot test its systems until the Medicare administrative contractors (MAC) are fully compliant. CMS recommended that providers forward information from their MACs to their vendor because CMS and MACs correspond with providers, not vendors.
5. Estimate the budget for transitioning to the 5010 transaction standard, taking into account costs for hardware, software, licensing, and training. The budget will vary depending on the practice size and the tools that your practice currently uses for coding and billing.
6. Plan the implementation beginning in early 2010. Review superbills at this time by crosswalking current codes to equivalent ICD-10-CM codes.
7. Develop a training plan. Focus on who needs training and how many hours will be required. Find out what resources are available and make a schedule.
8. Analyze business processes that are currently tied to ICD-9-CM. This could include medical policies and contracts with health plans.
9. Begin the education and training at least six months prior to the October 1, 2013, implementation deadline (for small practices). Large practices may need more time.
10. Address policy change development. Do you have contracts with Medicare Advantage plans or other health plans that base payments on patient severity of illness? For example, Medicare uses beneficiaries' characteristics (e.g., age and prior health conditions) in its CMS–hierarchical condition category risk adjustment model. The model uses ICD-9-CM diagnoses to predict expected resource utilization for each beneficiary. Medicare Advantage plans benefit from higher capitated payments when their covered lives are deemed high risk. There may be some new opportunities to appropriately improve payment with ICD-10 coding, which may better reflect your group's patient severity of illness.
11. Test the system (i.e., the deployment of the codes). Seek assistance from your vendor to do this. Make sure there is adequate time to perform the testing and allow for necessary internal customizations. The vendor should ensure that updates will be maintained during transition.
12. Track implementation compliance. Monitor all activities to identify potential problems after the implementation is complete. If payments are reduced or slower than usual, investigate whether the problems are related to a certain payer or are general in nature. A general slowdown could indicate that the problem is related to the practice's processes. Ask the following questions to track implementation compliance:
Are superbills used consistently and appropriately?
Are coders able to choose the correct diagnoses in a timely manner?
Are there delays in getting the claims final billed?
Do explanations of benefits indicate denials that were not present before the conversion to ICD-10-CM? Track what payers deny to determine whether there is a pattern to the denials.
Are other practices that use the same vendors or clearinghouses having the same problems?
This article was adapted from one that originally appeared in the November 2009 issue of The Doctor's Office, a HealthLeaders Media publication.
