The cost of caring for patients who are near death accounts for a big piece of the government's medical spending, but a furor over a provision for government-paid counseling to plan for end-of-life care is steering lawmakers away from the issue. Inside a sweeping House bill to overhaul the health system is a provision that would require Medicare to pay physicians to counsel patients once every five years. During those sessions, doctors could discuss how patients can plan for such end-of-life decisions. Opponents say the provision shows that architects of the healthcare overhaul want to ration seniors' care.
At a town-hall meeting in Indiana, Rep. Joe Donnelly, a Democrat in a conservative district, was told by constituents they don't trust the government to be their doctor. Two hours before Donnelly's scheduled arrival in Kokoma, 75 people were lined up for 72 seats. By the meeting's start time of 6 p.m., the number had swelled to about 500. A number of people carried signs supporting an overhaul, but the majority of questioners voiced strong skepticism about handing more responsibility for healthcare to the government.
The saying goes like this: There's no ‘I' in teamwork.
And as a hospital embarks on the arduous and costly journey toward an electronic health record (EHR), this saying couldn't be truer. The hospitals that achieve a successful EHR implementation are the ones in which the C-suite and HIM director work collaboratively to achieve the goal.
At Hoag Memorial Hospital Presbyterian in Newport Beach, CA, HIM Director Leslie Scarborough, RHIA, says an open relationship with her CIO played a large role in her being able to serve as a major contributor in the hospital's successful EHR implementation. "I think having the lines of communication open helps. My CIO is very open and knowledgeable about the HIM department and understands what we do," she adds.
Scarborough began reporting directly to the CIO four years ago when she became more active in the EHR initiatives at the hospital.
"I think it's worked in my favor," she says, adding that her collaborative relationship with her CIO has also scored her invitations to IT leadership meetings during which she could address back-end issues of how the EHR would affect the legal medical record, HIPAA compliance, and security and access to information.
Without the direct reporting structure, she says it would be difficult to interact regularly with her CIO and keep him abreast of the status on different projects. Currently, the two meet weekly to discuss various initiatives and their impact to HIM. "I think I'm really fortunate to report to someone who is really interactive and wants to understand," she says.
At McAlester Regional Health Center in McAlester, OK, e-mail is a vehicle used to keep the lines of communication open between the HIM department and CFO, says Glennda Gore, RHIA, vice president of corporate compliance and risk management. E-mails typically include a weekly list of unbilled accounts (dollar amounts) and daily transcription backlog reports.
In addition, the CFO is a member of the Utilization Review Committee and compliance work team, Gore says. During compliance team meetings, Gore says team members perform chart reviews and routinely review a DRG consultant's monthly report. "The CFO is there and hears the information at the same time that I do," she adds.
Gore says the CIO also works very closely with the HIS director, particularly when it comes to selecting EHR-related vendors and products. The CIO also works closely with the coding manager when selecting coding-related vendors and software.
"Our CIO is a member of our executive team, along with me, the CFO, CEO, CNO, etc." she says. "We meet as a group twice a week, and when we have a 'round-robin,' I can represent HIS/coding and bring up any issues at that time that affect IT, nursing, or the business office. She says this open communication has been helpful in achieving the organization's larger goals.
One of the most important lessons that I learned as a Girl Scout was: "Be Prepared." Whether it was preparing for a camping trip as a scout or later reporting and writing an article as a journalist, it's proved to be an important motto for living everyday life.
And, it's an important motto that hospitals and healthcare organizations are finding that they need to consider when communicating with discharged patients: Make sure those patients are prepared with sufficient information about their conditions in the post-discharge world concerned about 30-day readmissions.
Consider a new study by researchers from the Regenstrief Institute and the Indiana University School of Medicine that found that hospital discharge summaries were extremely inadequate in documenting both tests with pending results and information about which doctors should receive those test results.
The researchers noted that this poor communication could lead to serious medical errors.
Often during hospital stays, tests may be ordered by emergency department physicians, generalists, specialists, hospitalists, and other medical staff. These test results could indicate anything from a positive blood culture to declining kidney function, they said.
These are conditions that can require post discharge treatment, but oftentimes the results of some tests may not be ready for weeks after the patient has left the hospital. Most patients may find themselves unprepared: They and their healthcare providers are unaware that test results are pending—until it might be too late.
In the study, which appears in the September 2009 issue of the Journal of General Internal Medicine, 668 hospital discharges with pending test results were examined. The researchers analyzed the discharge summaries and found them deficient:
While all of the patients had pending test results—only 16% of the 2,927 tests with pending results were mentioned in the discharge summaries.
Only 67% of discharge summaries indicated which primary care outpatient physician would be responsible for following up with the patient after discharge.
Since the researchers examined the discharge summaries retrospectively, they were able to see if test results reported after discharge called for changes in a patient treatment plan or in management. What they did discover surprised them.
"We found that a huge number—72%- of test results requiring treatment change were not mentioned in discharge summaries. So an outpatient provider likely would not even have known that the results of these tests needed to be followed up," said Martin Were, MD, a Regenstrief Institute investigator and an assistant professor of medicine at the Indiana University School of Medicine.
"In the patient safety arena, this is what you call a 'fumbled handoff'—and it leads to medical errors," Were added. The study puts the spotlight on the need to improve "how information is communicated to the outpatient follow up providers."
And it's not only test data that patients should be aware of. In my recent HealthLeaders magazine article on reducing hospital readmissions, I spoke with Brian Jack, MD, associate professor and vice chair of the department of family medicine at Boston Medical Center, who was behind the development of Project RED (which stand for "reengineered discharge").
Project RED lists 11 points to talk about with patients before discharge—including discussing with the patient "any tests or studies that have been completed in the hospital and . . . who will be responsible for following up the results."
"What we did basically was to collect information in the hospital that was relevant to people that allowed them to take care of themselves when they went home," Jack said. In other words, it let them be prepared—avoiding the fumbled handoff that could end them back soon in the hospital.
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The American College of Surgeons is criticizing President Obama's comments about the financial incentives that might encourage a surgeon to amputate a diabetic's foot. He claimed the reimbursement is $30,000-$50,000, but the ACS points out that Medicare pays $740-$1,140 for the procedure.
Doctors aren't currently reimbursed for discussing end-of-life issues with patients, and many physicians, including the AMA, welcome the provision in the House healthcare bill that would begin compensating them for counseling patients. Cecil Wilson, AMA's president-elect, described the opposition to the provision as "one of the more egregious examples of mischaracterization that I have seen."
There are several dimensions to consider when evaluating whether a potential physician recruit will be a good fit for the hospital or the community, including:
Commitment to quality and service. Placing a high priority on a culture of quality and safety will help a hospital attract and retain the best physicians. By the same token, physicians who are not willing to adhere to the highest standards of quality and patient service will not be comfortable with the scrutiny they will face. Physicians unwilling to be measured against clinical benchmarks and patient satisfaction norms will not be good additions to the medical staff.
Commitment to vision and values. Successful healthcare organizations have strategic plans that include a well-articulated mission, values designed to shape behavior at all levels, and a compelling vision of what the organization seeks to accomplish within the next three to five years. New physician recruits should embrace the organization's values and be willing to make an enthusiastic commitment to the organization's future.
Comfort with physician colleagues and practice expectations. Recruits should be told about the makeup of the existing medical staff such as what percent of physicians are in primary care versus specialty care, what percent are board certified, what percent are fellowship trained, how many are recognized as ?top docs? in the area, how many are nearing retirement, and where the most respected physicians went to medical school and received their residency training.
Recruits should be given additional information about other physicians in their specialty, such as how long they've practiced in the community, whether their practices are accepting new patients, their prevailing work ethic (e.g., the size of the average patient panel, the number of admissions they generate, the number of surgeries or other procedures they perform, and the extent of their on-call responsibilities), and whether they attract patients from outside the service area or whether patients leave the community for care. The hospital should also facilitate face-to-face meetings with established young physicians to help the recruit understand the dynamics of establishing new referral relationships and building a practice in the community.
Enlisting staff and community support
Many examples exist of new physician recruits unable to build a sustainable practice in a community, despite a demonstrated community need for physicians in their specialty. Sometimes, this occurs because one or more physicians on the existing medical staff subtly discourage referrals to the newcomer for fear they will lose patients and practice income. Other times, the physician simply does not become well-known in the community.
The best approach to avoid this situation is to enlist support for the new recruit within the medical staff and the community early in the recruitment process. Sharing the results of the community need analysis with medical staff members is one way to clarify the opportunities for new and existing practices. Sharing the results of the annual physician survey is another proactive strategy, especially when the survey documents dissatisfaction with the current breadth, depth, or quality of the existing medical staff in the given specialty.
If a new recruit represents a new specialty or subspecialty, adds an important new clinical capability, or meets a critical need in the community, the physician's impending arrival should be featured in newsletters mailed to the community or highlighted in postings on the hospital Web site. The advance notice to the community should be part of a formal marketing plan that builds enthusiasm and support for the new recruit by underscoring how the community will benefit from the added capabilities the physician has to offer.
The new physician should also make personal visits to established physicians who are potential referral sources to explain his or her unique capabilities and practice style. Within allowable guidelines, all new practices should receive support from the hospital in the form of advertising, media exposure, open houses, introductory meetings, and other means of connecting new physicians to potential patients and colleagues.
Massachusetts enacted universal healthcare three years ago, and since then many have looked at us as a potential model for the nation. We've insured close to 98% of our population, adding nearly 450,000 to the insurance roles—an enviable achievement. But the strains are evident.
With physician shortages, especially in primary care, we've discovered that universal coverage does not mean universal access to care. Some patients are having difficulty finding a primary care doctor, and long wait times exist. And like others, we struggle mightily with the cost issue, exacerbated by a shrinking budget battered by a severe recession.
But the will to succeed exists, and we move ahead. A special panel on payment reform has recently recommended a new way to pay hospitals and physicians, with the goal of reducing costs.
Reforms at the state and federal levels aim to improve quality, reduce costs, and make healthcare more affordable. Physicians know that rising costs are unsustainable for the individual, the employer, and governments. We also know plenty of opportunity exists to improve the quality of care.
Physicians want to be—and should be—part of the process to build a better healthcare system. We are, after all, those who deliver the care. But this willingness is tempered with a certain degree of concern, born of experience. The last two decades have produced many big ideas to improve quality and affordability, launched with high hopes and great expectations. But most of these notions have failed, often making matters worse and driving a wedge between patients and their physicians.
Our hope for reform, at all levels, is that efforts, besides enhancing care and cutting costs, will restore dignity to the patient-doctor relationship.
Physicians believe there must be four cornerstones to healthcare reform, each patient-centered and each as important as the other:
Healthcare spending must be affordable and sustainable. Volumes of evidence prove that when people can't afford healthcare, they don't take their medications, see their doctor, or engage in preventive care. People who defer their care get sicker, and treating them becomes more expensive and more difficult.
Spending levels must be sustainable and realistic to provide the care that patients need. One important lesson from past efforts is that cutting hospital and doctor payments alone doesn't create long-term savings, even if they succeed in squeezing out short-term savings. There needs to be a systemic approach to developing sustainable spending, or the short-term savings cannot be sustained.
Reform must support and promote high-quality care. Cutting costs without promoting quality will not be accepted by patients or physicians and would doom any effort.
Reform must support a diverse, pluralistic healthcare system—large and small hospitals, independent practices, community health centers, nursing homes, rehabilitation facilities, home healthcare, mental health, dental care, and all venues where high-quality, high-value care is delivered. Patients value choice, a value deeply embedded in our culture. Any reform that deprives people of meaningful choice will not succeed and will hinder progress.
Current proposals could make things better, but only with great care and extreme diligence. Moving to a new system will require a careful, orderly transition taking many years. Physicians will need time, funding and training to acquire the technologies, to learn how to manage this new financial risk, and to acquire expertise in new areas of the law and governance. Further, practices are not equally ready to move to a new system, and some areas of the country are better equipped to do so than others. In particular, practices in the less-populated would be especially disadvantaged by an overly rapid movement to a new system.
In a similar way, patients will also need time to familiarize themselves with a new system. They will have new roles and responsibilities, and their transition needs must be designed just as carefully.
We all know that the status quo in healthcare is not an option, and much hope has been placed in these new efforts. We subscribe to President Obama's statement that we should keep what works and improve what isn't working. Let's use the wisdom we've gained from past experiments to guide us to effective, long-lasting reform.
Mario Motta, MD, a cardiologist in Salem, MA, is president of the Massachusetts Medical Society.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
After struggling to control the healthcare reform debate this summer, the Obama administration recently ratcheted up rhetoric against health insurance companies, hoping to make its narrative more compelling by adding a villain to rally against.
But insurers, represented by America's Health Insurers Plans, aren't quietly submitting to the new role. They've poured millions into public relations and have worked with the administration in an attempt to clean up their image. And knowing they can't successfully fight back aggressively against the president, they are now instead trying to divert the blame and anger to someone else: Physicians.
At least, that seems to be the point of a recent survey released by AHIP that portrays physician charges, rather than insurance industry practices, as the driver behind rising healthcare costs.
AHIP asked insurers for information about some of the highest bills submitted to them in 2008, and the results are certainly eye-catching. The New York Times took the bait in an article that highlights a $12,712 bill for a cataract surgery (Medicare only pays $675 for the procedure), a $20,120 charge for a knee operation (Medicare pays $584), and a $72,000 fee submitted by a physician for a spinal fusion (Medicare fee: $1,629).
The organization admits that it didn't collect data on the frequency of such high fees, so it's not quite accurate to call it a survey—surveys are meant to be representative, but this is a deliberate cherry picking of outliers.
Do some doctors submit outrageous bills for out-of-network procedures? Yes, it happens. But to suggest physician charges (which often aren't fully reimbursed) are primarily driving healthcare costs is dishonest.
In fact, another survey released this week by the Medical Group Management Association shows that most physician practices are struggling financially as operating costs rise more rapidly than revenues. Some of their biggest challenges include collecting what they are owed from patients and negotiating contracts with insurers.
The real problem the AHIP survey highlights is the lack of transparency in the healthcare reimbursement system, and the problem is not limited to physician charges. Doctors often submit a bill not knowing how much the insurer will pay, or if it will pay at all. Patients are also typically in the dark, both about what the physician will charge and whether the insurer will deny their coverage.
Healthcare consumerism has failed because no one involved can figure out the pricing system. Insurers can point fingers at physicians, but that doesn't absolve their portion of the blame in the problem.
Deflecting the anger to physicians may backfire if doctors take up Obama's call to arms against insurance companies in retaliation. Polls show that Americans trust physicians more than other group to recommend the right thing for reforming healthcare.
The group they trust the least? According to the Gallup survey, aside from Republicans in Congress, it is health insurance companies.
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The list of issues will likely be familiar to healthcare providers who saw those announced by Connolly Healthcare last week. HDI has posted the following approved issues:
Neulasta (HCPCS code J2505). RACs will review claims submitted with the total number of milligrams instead of one unit per 6mg. Providers should submit claims for J2505 so that the units billed represent the number of multiples of 6mg administered, not the total number of mgs.
Newborn Pediatric CPT Codes Billed for Patients Exceeding Age Limit. Certain service codes are specific to patients of a specific age and should not be applied or billed for patients who exceed the age limit defined by the CPT code.
Once in a Lifetime. Certain procedures are only performed once in a person's lifetime. RACs will seek to identify claims paid for those procedures for more than one service date.
Excessive Units—Untimed Codes. When reporting service units for untimed codes (excluding modifiers -KX and -59) where the procedure is not defined by a specific time frame, the provider should enter a "1" in the units bill column per date of service.
Excessive Units—Blood Transfusions. Providers should bill blood transfusions with a maximum of one unit per patient per date of service.
Excessive Units—Bronchoscopy. Providers should bill bronchoscopy services with a maximum number of one unit per patient per date of service.
Excessive Units—IV Hydration. Providers should bill IV hydration with a maximum number of one unit per patient per date of service.
"These issues are perfect for automated reviews," says Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc. "These issues are definitely clear cut. RACs wouldn't need to request medical records for these."
But that doesn't mean the issues the RACs have chosen to begin with aren't surprising. Mackaman says many providers expected RACs might audit for incorrect Neulasta billing and speech therapy untimed codes. But other choices, such as the newborn codes billed for patients who have exceeded code age limits and "once in a lifetime" procedures, are unanticipated.
"It's not exactly what we may have expected," Mackaman says. "But it must be that they found these to be important through their data mining."
HDI's list of approved issues also includes the date CMS approved the issue, as well as relevant claim types for each issue, and where providers can find additional information on each topic.
With two RACs now focusing on the same issues, it seems prudent for providers everywhere to review these areas and try to correct any problems they uncover. Mackaman suggests meeting with various departments involved in each of the specific issues. Talk to rehab departments about untimed codes, talk to the pharmacy about Neulasta, and talk to the HIM department about what could be causing the coding problems related to newborn pediatrics, she says. And review documentation for IV hydration as well.
The list is out there, so be proactive, urges Mackaman. "Don't wait until you receive a RAC letter to begin to review your processes."
The new HDI Web site also includes a section of RAC FAQ, information about RAC region D, and other information for healthcare providers.
