Swine flu in the United States exposed gaps in the supply chain that delivers medication, masks, and even testing swabs to hospitals and doctors' offices. The shortcomings could prove vastly more worrisome if a deadlier strain returns in the fall, officials say. In Massachusetts, the administration of Governor Deval Patrick is asking the Legislature to spend $1 million more to bolster the state stockpile, a request that is pending.
Medical residents may be considered as full-time employees whose pay is subject to Social Security taxes, a federal appeals court ruled. The Eighth Circuit U.S. Court of Appeals reversed two district court opinions that had concluded the U.S. erred in collecting Social Security taxes from medical residents at University of Minnesota and the Mayo Foundation for Medical Education and Research. The three-judge appellate court panel said the U.S. Treasury Department has latitude to interpret the IRS Code and made a "permissible interpretation" that medical residents are full-time employees subject to payroll taxes.
One of the policy questions that AMA delegates will consider at their annual conferenc is whether doctors should forgo their iconic white coats for something a little less dangerous for patients. The measure would urge hospitals to adopt dress codes of "bare below the elbows," to avoid carrying bacteria between patients via coat sleeves.
Much of the discussion surrounding the healthcare reform debate so far has focused on President Obama's proposal for a government-sponsored health plan that he says will reduce costs. Insurers and doctors argue it will limit patient choice, while drug companies warn that the quality of care could be compromised. But Obama's proposal is only one of many that await Congress as it wrestles with how to rein in exploding healthcare costs while taking care of the country's nearly 50 million uninsured.
Almost 30 key lawmakers helping draft landmark healthcare legislation have financial holdings in the industry, totaling nearly $11 million worth of personal investments. The list of members who have personal investments in the corporations that will be affected by the legislation includes Congress's most powerful leaders and a bipartisan collection of lawmakers in key committee posts. Their total healthcare holdings could be worth $27 million, because congressional financial disclosure forms require reporting of only broad ranges of holdings rather than precise values of assets.
The White House is caught in a battle over how to finance a comprehensive overhaul of America's healthcare system, as key Democrats advocate a tax plan that could require President Obama to break his campaign pledge not to raise taxes on the middle class. Obama and congressional leaders have vowed to pay for a sweeping expansion of the healthcare system without additional borrowing. Much of the money is likely to come from reining in spending on federal health programs for the elderly and the poor. The rest of the cash will probably come from new taxes, but Democrats are deeply divided over which taxes to raise.
The number of fertility or in vitro treatments continues to rapidly increase, and half of the 54,656 infants born in 2006 as a result were twins, triplets, or higher multiples, according to the latest in a series of federal reports on the issue.
And it's getting increasingly expensive for all healthcare payers. The number of births from these technologies resulting in premature or low-birth weight newborns is an economic burden to hospitals and payers around the country, amounting to $1 billion in 2005 dollars, the Centers for Disease Control and Prevention report said.
Since 2001, the number of live birth deliveries—those in which one or more infants were born—that were made possible by assisted reproduction methods, such as in vitro fertilization, rose 41% and the number of infants born as a result increased 34%. The number of medical centers offering the procedure also has increased, from 421 to 483.
Despite recommendations that reproductive medicine specialists limit the number of embryos transferred to one or two for women under age 35, the CDC paper said that approximately 16% of procedures involved the transfer of four or more embryos and 5% involved the transfer of five or more.
That indicates that throughout the U.S., recommended guidelines are not being followed.
In 2006, the American Society for Reproductive Medicine and the Society for Assisted Reproductive Technology lowered the number of recommended embryo transfers for women under 35 from 2 to 1. But it maintained recommendations of two embryo transfers for women between 35 and 37 and "no more than three" for women 38 to 40. For women over age 40, the guidelines allow five embryo transfers, and says physicians may modify the practice based on "extraordinary circumstances."
According to the CDC report, "In certain states, ART [Assisted Reproductive Technologies] procedures are not covered by insurance carriers, and patients might feel pressured to maximize the opportunity for live-birth delivery by transferring multiple embryos." They add that many physicians may want to maximize their publicly reported success rates, which may be defined solely as the percentage of total live-birth deliveries.
The popularity of such techniques, however, is a growing public health concern. Because the procedures are more likely to result in multiple births, they also produce higher rates of complications, such as premature delivery, low-birthweight babies, and long-term disability, as well as complications for the mother, the CDC said. The agency has reported birth outcomes on a variety of the procedures since 1997, as required by law.
The field of ART is generally a moneymaker for hospitals because most women undergoing the procedures either pay the cost themselves or are covered by private health insurance, hospital officials said. When complications arise, the costs are absorbed by health plans in higher premiums paid by employers and the insured. But increasingly, administrators are seeing couples saving for the procedure or using stashed-away funds or inheritance, as a last ditch effort as they fear the biological clock running out.
The financial burden comes when complications arise.
"Even though private insurance pays a large percentage of the cost of caring for these newborns, it can be expensive for the health insurance industry overall," says Thomas Moore, MD, director of the Obstetrical Service at UCSD Medical Center.
"At $2,000 to $3,000 a day for intensive care, which can continue three and four months, that's a cost that raises premiums across the board," he says.
These days, many couples may have health insurance when they start the procedures, which can cost several thousand dollars per cycle. But high deductibles or loss of health insurance as a result of a layoff may leave them unable to pay the exorbitant costs of complications, both for their newborns and themselves. In some instances, the government must step in and foot the bill.
ART procedures are most common in California, which claims one in seven procedures performed in the U.S., followed by New York, Illinois, New Jersey, and Massachusetts.
A case in point is the well-publicized case of Nadya Suleman, or "Octo-mom," who was on welfare and Medi-Cal, California's version of Medicaid, when she underwent fertility treatments and subsequently gave birth to octuplets.
The cost of caring for her and her babies was estimated at $1 million.
Past president of one professional society of reproductive medicine, David Adamson, MD, of Palo Alto, CA says the "Octo-mom" incident was an unusual one. "Nobody in our field is arguing for multiple pregnancies as an ideal outcome," he says, adding that endocrinologists have reduced by a factor of four the number of triplet births between 1996 and 2006.
Not all patients are ideal, he adds, explaining that legal issues make the situation more complicated. "I'm not going to tell you there's not tens of thousands of cycles (procedures). But quite frequently patients demand more embryos be transferred. Legally, it's not possible for a doctor to refuse that demand without being sued. The doctor does not have the legal right to tell the patient what to do with her embryos."
CDC officials who authored the report advise stricter counseling and warning for women or couples who want to risk the procedures.
"Assisted reproduction technology-related multiple births represent a sizable proportion of all multiple births nationwide and in selected states," the CDC report said. "To minimize the adverse maternal and child health effects associated with multiple pregnancies, ongoing efforts to limit the number of embryos transferred in each ART procedure should be continued and strengthened."
The authors added that adverse maternal and infant outcomes should be explained thoroughly when counseling patients considering ART.
Another tactic some hospitals take is to monitor infection control through "mystery shoppers" who secretly note the behavior of employees.
The advantage of mystery shoppers, at least in the infection control world, is that they capture typical compliance rather than reactionary conduct, says Gayle Lovato, MS, RN, an infection preventionist at Inova Loudoun Hospital in Leesburg, VA.
For example, it's nearly impossible for infection control professionals to accurately observe hand hygiene practices during rounds. "People tend to run screaming to the closest sink when they see us," says Lovato, whose hospital uses mystery shoppers.
Medical centers can use secret shoppers to track a variety of infection control concerns, including steps to thwart urinary tract infections, proper use of gloves and masks, and observing isolation precautions.
Who you can recruit
Inova's mystery shopper program for hand hygiene uses infection control trainers to perform the surveillance. There is one trainer per unit, and he or she monitors staff compliance with hand hygiene regulations and then documents the findings on a standardized report form. Each trainer performs an average 10 observations a month, says Lovato.
To entice volunteers, Inova offers a step increase for secret shoppers. This gives staff members a small incremental pay increase, similar to what they would get for participating on a hospital committee, says Lovato.
Every month, Inova issues a report card that lists the compliance rates for each unit. "The observations are not scientific, they're random, but overall I think they give us a pretty good snapshot," says Lovato.
The hospital uses these hand hygiene figures to spot trends and see where problem areas exist. For example, if a particular unit has a high incidence of noncompliance, Lovato looks for opportunities to perform staff education or to improve systems issues, such as making alcohol-based hand sanitizer more readily available.
Widespread appeal to clandestine scrutiny
Mystery shopping has increased rapidly in hospitals in recent years, mainly from the perspective of sending in actual or stand-in patients to assess the quality of customer and clinical service in a medical facility.
Although many healthcare organizations are measuring patient satisfaction, their data don't always pinpoint the experiences behind the scores. Mystery shoppers fill in the fine details and help hospitals understand how patients feel about their experiences, apart from how they feel about their medical treatment.
There are a number of barriers to overcome before starting a mystery shopper program, says Brian Hudson, MT (ASCP), CIC, an infection preventionist at Cleveland Regional Medical Center in Shelby, NC.
Cleveland Regional also users secret shoppers to monitor handwashing. His biggest challenge has been recruiting people to take the job. "Nobody wants to be thought of as a rat," he says. "It's viewed as tattling."
Lovato says, however, there is no reason for staff members to view the job as a negative. Shoppers should know that they perform an important service by protecting patient safety. Offering an incentive, such as the additional pay step, is one way of overcoming an individual's unwillingness to take the position, she says.
It's important to let shoppers know they're appreciated to encourage participation. Lovato meets with the mystery shoppers monthly, sometimes at a catered breakfast meeting.
"We try to make it a fun role," she says. "We bring in speakers. Sometimes drug reps will do a presentation on infectious diseases or issues." The facility also hosts a holiday party for mystery shoppers and thanks them for their work in the hospital's internal newsletter.
Sen. Chris Dodd (D-CT), chairing the Senate Committee on Health, Education, Labor, and Pensions hearing on its healthcare reform bill Thursday, aimed his questions at the American Medical Association after a New York Times story noted that the AMA opposed a public insurance option.
The AMA distanced itself from the story in a statement released yesterday, which said the story had created a false impression about the AMA's position on a public plan option. However, speaking before the committee Thursday, Samantha Rothman, a member of the AMA's Board of Trustees and a fellow in pediatric emergency medicine in Boston, said the "AMA strongly opposes a public health insurance plan operated by the federal government with a pay schedule that is based on Medicare."
She also said that "the AMA strongly supports making affordable health insurance available to all Americans," and that this can "best be achieved through a combination of insurance market reforms and healthcare exchanges that offer a variety of affordable private insurance plans."
She added that the AMA was "open to consideration of a new health insurance option that is market-based and not run by government"--but she did not name the policy. "Though several concepts have been publicly discussed, no legislative details have yet been put forth and we do look forward to reviewing those ideas."
But Dodd, who is chairing the committee while Sen. Edward Kennedy (D-MA) recuperates from a brain tumor, wanted to know more--especially given that the committee is examining a public plan option, which was not detailed in the bill released on Monday.
"Give us some ideas -put some more flesh on this, as you will, other than just sort of a vague concept here that you're willing to support something other than a public option," said Dodd.
Again, Rothman said the AMA position is "that we think this can be done with market reforms in the private insurance market, but we're very interested in some of these alternatives." One of the alternatives, she said, is the federally chartered cooperative plan unveiled earlier this week by Sen. Kent Conrad (D-ND). But the AMA would "really need to see more details of those plans before we can comment specifically."
CMS created the Recovery Audit Contractors program as part of an effort to reduce improper Medicare payments by contracting independent auditors to detect and collect overpayments. The auditors are also charged with identifying underpayments although during the RAC demonstration phase about 25 times more overpayments were collected than underpayments paid ($980 million vs. $37.8 million).
The demonstration project, which ended its three-year process in March 2008, is the best body of evidence we have to project what the permanent program will be like. The permanent program continues to roll out across the country, with the goal of having all four RAC regions, each responsible for a quarter of the country, fully operational by 2010. Hospitals and other healthcare organizations interested in preserving their Medicare revenue—including already billed and collected funds—would do well to study the demonstration and learn as much as they can to prepare for a future where RAC audits will soon become an unavoidable reality.
Following are some of the insights my organization gained working with several hospitals affected by the demonstration project to the tune of hundreds of millions of dollars. In our work appealing those retroactive denials, we were able to achieve 93% successful overturn rate at the fiscal intermediary level. While we learned a great deal about successful appeal and prevention strategies, we also found the appeals process to be fairly opaque and arbitrary—a situation we hope will be remedied over time as CMS works out the kinks in the permanent phase.
Lessons learned
As a part of our work for a large academic teaching hospital in New England we pursued about $4.2 million worth of appeals on a set of 72 claims. Our experience with this group of appeals highlights some of the odd and seemingly arbitrary aspects of RAC denials and appeals:
The claims were all very similar: inpatient implanted defibrillator procedures flagged by the auditor for "wrong setting." The hospital had actually performed 92 of these as inpatient procedures within the look-back window, but we were never able to get a clear answer as to why the 72 were denied but the other 20 were not.
We appealed all 72 to the FI level: 64 were approved, eight still denied. Those eight were appealed at the Qualified Independent Contractor level and denied there as well. No satisfactory explanation was ever given at any level for the difference between the eight and the 64.
We are currently appealing at the Administrative Law Judge level.
A few interesting points to note from this and other similar cases:
Certain procedures seem to be getting the most attention from RAC auditors:
High-cost, short-stay procedures like defibrillators, stents and peripheral angioplasty performed on an inpatient basis
DRGs where principal diagnosis sequencing is questioned, such as respiratory failure
One-day medical stays for chest pain, back pain, gastroenteritis, congestive heart failure, etc.
Three-day stays with a transfer to skilled nursing facility
The vast majority of denials were for inpatient claims and half of those were "wrong setting" denials
The grounds for both the initial denials and the subsequent appeals decisions are unclear. Organizations should continue to escalate to the next level of appeal until they receive a rational response.
These opaque adjudication procedures also make it very difficult to know on what grounds denials should be appealed. We recommend building a library of successful appeal letter templates.
Appeals can be very tough. One claim which included a charge of more than $5,000 was denied at the QIC level because the admission order was not dated.
RAC Inoculation
So, what can you do to protect your organization from RAC auditors and be best prepared if and when they do come knocking?
Be forewarned: Assessing your risk is an important first step to understanding how big of a problem RAC could be for you. Review historic claims against RAC findings to get a ballpark estimate of how your organization would fare in an audit.
Be efficient: As you build your RAC processes, focus on efficiency in your work flows, reuse documents wherever possible and always be on the lookout for ways to streamline your processes. New RAC workflow and documentation tools are coming to market now that can help.
Be aware: RAC correspondence is often sent to the hospital's general delivery mailbox, and many organizations are not set up to alert the right people immediately when this occurs. Payment retraction can be halted if FI-level appeals are filed within 30 days and QIC-level appeals within 60, so make sure your staff are trained to spot these letters immediately.
Be persistent: Especially when it comes to large value claims, we see no reason not to appeal all the way to the FDC level until standards emerge for what denials will and will not be overturned and why.
Be consistent: Many billing organizations find themselves torn between clinicians seeking to provide the safest, highest-quality standards of care on one side and RAC auditors making them pay for exceeding basic thresholds of quality on the other. We are working with a number of organizations to write their own "RAC Rulebook;" setting out well-substantiated standards of care for the organization and using that document to fend-off both groups. The idea is to make both internal and external organizations prove their case against your evidence.
Living in a RAC world
While RAC may create an undue administrative burden on healthcare organizations, and it may wind up triggering unintended consequences, RAC is clearly here to stay. As healthcare professionals we can only work toward smoothing the rough edges as we go and hope for a more just and transparent and system once the kinks are worked out.
In the meantime, healthcare organizations with significant Medicare populations will be wise to get their RAC houses in order and seek professional help when they need it.
Karen Bowden is the president of consulting services for ClaimTrust Inc. She may be reached at Kbowden@claimtrust.com.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
