"To say the least, I am personally very disappointed. Not that my opinion should be the driving force on a decision that may affect the lives of thousands of people,” wrote Len Lichtenfeld, MD, the American Cancer Society's CMO, on his blog. "It was an opportunity to start setting the stage on how we can do things the right way in healthcare going forward, which will be a critical part of any reform effort.”
CMS says it decided against covering CT colonography after evaluating health outcomes for people ages 65 years and older and determining that "the evidence is not sufficient to conclude that screening CT colonography improves health benefits for asymptomatic, average risk Medicare beneficiaries.”
"While it is a promising technology, many questions on the use of CT colonography need to be answered with well designed clinical studies that focus on health outcomes for the Medicare population,” CMS wrote in its summary. CMS reportedly spent $16 billion on various scans in 2006, which is double what it spent in 2000.
Colorectal cancer is the third most common cancer among both men and women in the United States. About 140,000 new cases of colorectal cancer are diagnosed each year, and about 50,000 people die because of late detection, says James H. Thrall, MD, chair of the American College of Radiology.
"Make no mistake: If let stand, this CMS decision not to pay for CT colonography will cost lives,” Thrall says. "For CMS to turn its back to a technology that can attract more patients to be screened and save countless lives is deeply concerning. CMS should reverse this determination immediately or Congress should step in and vote to mandate coverage of CTC.”
A recent study by National Cancer Institute found that a CT colonography is as effective as a standard colonoscopy to screen for cancer and precancerous polyps. The American Cancer Society last year added CT colonography to its list of recommended colorectal cancer screening exams. The National Cancer Institute Colorectal Cancer Progress Review Group has estimated that wider use of screening could save 20,000 lives annually.
Several major private health insurance companies, including CIGNA and UnitedHealthcare, cover CT colonography. Elizabeth McFarland, MD, chair of ACR's Colon Cancer Committee, says CMS' decision to drop CT colonography creates two-tiered coverage that will adversely impact poor, minority, and underserved areas.
"This noncoverage determination is a setback to efforts to provide better care to underserved areas of the population," McFarland says.
Kaiser Permanente Bellflower Hospital in Los Angeles has been assessed a $250,000 fine because 23 employees at a number of Kaiser facilities with access to electronic medical records unlawfully breached the privacy of a patient who gave birth to octuplets earlier this year.
It is the first fine of its kind under a new state law that went into effect Jan. 1 designed to protect patient privacy, state officials said today.
Under another state law, the 23 individuals who engaged in the breach were referred for investigation and other charges could be filed by another state agency, the Office of Health Information Integrity. There also is the possibility that those responsible could see the loss or suspension of their medical licenses.
"As a byproduct of that investigation, Kaiser terminated one employee, 14 resigned, and eight received disciplinary action," said Kathleen Billingsley of the California Department of Public Health, Center for Health Care Quality.
Billingsley said that after Kaiser became aware of the breach, it put a banner on computer monitors warning providers "that if they are accessing medical records, they must have authorization and a need to do so," Billingsley said.
"But six of the breaches occurred after the confidential banner was in place," Billingsley said. "Seven employees accessed it more than once."
Asked what hospitals can do additionally, she suggested possibly requiring that anyone accessing a medical record be required to insert a code. "I would go in there and indicate through my code that I'm accessing that record, so there's immediately a link between myself as a healthcare professional that I am accessing that record."
She said other solutions may be found through innovative software security measures.
According to the state investigation's statement of deficiency, the employees who accessed the record "had no business to know. Had no permission to look" at her medical record.
Kaiser is now required to produce a plan of correction that must be accepted by the state, It can appeal the decision, although it is not known whether it will.
Billingsley and Mark Horton, MD, director, California Department of Public Health, made the announcement with stern language that future violations will not be tolerated. "Medical privacy is a fundamental right," he said. "Patients should not have to worry about who is viewing their private confidential information. That is critical."
The $250,000 fine is the highest allowed for such a violation under legislation that took effect Jan. 1. The law was enacted after numerous confidentiality breaches involving celebrities, such as Farrah Fawcett.
Additional fines of $17,500 may be assessed for subsequent violations by the same hospital.
State officials did not say whether any of the individuals known to have improperly accessed the patient's medical record were responsible for leaks to news media. But the ensuing publicity identified the patient as Nadya Suleman, who gave birth to octuplets in January.
In today's economy, hospital executives are realizing that the variables they can control are quickly being dwarfed by the size of the problems they cannot control. This is a good time for executives to revisit clinical protocols as a way to position their hospitals in the face of a chaotic marketplace.
Clinical protocols are also a way to engage physicians who are more aware of their role in hospital operations than they were a decade ago. By taking the first steps to establish a clinical protocol committee, hospital leaders can bring physicians into the process of developing, updating, and improving clinical effectiveness. By bringing together stakeholders in this way, hospitals are better able to control their costs while also finding innovative ways to deliver quality patient care.
To understand the impact that clinical protocols can have in today's hospitals, it is important to understand the following:
The troubling economic trends that are impacting hospitals, physicians, and patients
The importance of clinical protocol committees in the face of economic challenge
The best way to develop an effective clinical protocol committee
Troubling trends
Before delving into the reasons for updating protocols, take a minute to review some of the troubling trends that are emerging. The data clearly show that hospitals are facing many simultaneous negative pressures—unprecedented in our time—and they are being forced to look at innovative ways to control costs while maintaining quality care. Some of the most critical trends that are simultaneously facing hospitals, physicians, and patients today include:
Patients are delaying medical care. Last year, 20% of Americans reported skipping or delaying medical care, up from 16% in 2006. This trend is resulting in more critical, costly care in the long run.
Hospital revenue streams are changing as unemployment rises. Commercial insurance enrollment is down to 54.6% in 2009, compared to 59% in 2008, while Medicaid enrollment has grown from 11.9% to 14.5%. These shifts are negatively affecting hospitals' net revenues as the mix of reimbursements change and self-pay patients increase in number.
Medical staffs are feeling the impact of a troubling economy and government oversight. The American Hospital Association's recent survey (November 2008) showed that 56% of surveyed hospitals are reporting an increase in the number of physicians seeking financial help through all sorts of mechanisms—from joint ventures to employment arrangements to ED call pay. The federal government is also changing the rules for how hospitals and physicians can affiliate, and is creating new options and models to be explored.
The federal government is trying new and sometimes punitive approaches to control rapidly growing expenditures. CMS is trying such approaches as linking payments to quality, bundling payments, and initiating payment penalties for avoidable readmissions. At the same time the Senate Finance Committee is proposing measures that would move from a focus on quality reporting to taking 5% of CMS DRG payments from all hospitals and paying it back as a bonus for value outcomes. Only the top 25% of hospitals would receive the full bonus, the lowest 25% would receive none. Those in between would receive a portion. Essentially, those hospitals that may need the most help may receive the lowest payments.
As a result of these and other pressures, many hospitals are attempting to reduce their cost profiles in both the short term and the long term. In addition to the other difficult cost-cutting measures that hospital executives are undertaking, they should also revisit clinical protocol committees. Such committees can ensure effective patient treatment and position the hospital to take advantage of changing forms of reimbursement while benefitting the operational health of a hospital. Given the size of the chaos that hospitals and the country as a whole currently face, there may be less resistance to the concept.
Physician pushback eroding
Historically, physicians pushed back against protocols and resisted being told "how to practice medicine." Physicians usually voiced some common concerns: their training was likely better than those who are designing the protocols, their patients were sicker than the norm, or standardized protocols limited innovation. The lack of protocols, however, can have far-reaching consequences. For example, one 700-bed hospital chose to stay away from protocols and case management because of pushback from physicians. Upon review of the quality of this hospital's outcomes, it was poorly rated by national agencies, patients' length of stays were excessive due to delays in receiving routine tests, and services were dramatically overutilized. This represents a tremendous waste of resources and an increase in costs that could otherwise be avoided.
The recent economic downturn gives hospitals a good reason to revisit their protocols and most physicians can appreciate the rationale for looking at changes in the delivery system, even if they do not fully support the identified changes. Likewise, given the financial pressures that physician practices are facing, doctors are likely to appreciate any additional paid work in the form of serving on committees. Finally, serving on a protocol committee provides physicians with input in the process of identifying quality patient care while also balancing economic factors.
Most physicians and hospital staff join protocol committees with the shared goals to:
Improve every patient's quality of care.
Improve patient throughput.
Lower the ALOS by determining a treatment plan in advance so care is coordinated in a more organized manner.
Reduce readmissions because patients are healthier when they leave or because the protocol dictates that follow-up care take place.
Increase the nursing staff's role in patient treatment, thus freeing up physicians to see more patients.
Reduce supply costs by reducing the variation in types of medicines used.
Improve documentation because any variances from the protocol are documented.
Prepare for the coming changes in reimbursement.
Developing an effective clinical protocol committee
The concept behind clinical protocol committees is fairly straightforward—stakeholders are tasked with developing the highest quality, most cost-effective treatment pathway for a given illness and making that pathway the standard for how those patients will be treated. (Comparing clinical effectiveness is a more contemporary term that means much of the same.) Here are suggestions for taking the first steps towards developing a committee:
Offer opportunities for every physician to be involved to some degree and make sure that the most highly respected physicians sign off on the end result.
Include those physicians who are the most likely to be resistant. In the past, these physicians may have intentionally skipped critical meetings. Some hospitals believe that paying physicians to attend the meetings and to help develop the protocols is allowable under Stark, especially if they have to attend the meetings to receive payment.
Be inclusive of the staff. Dietary and materials management may not need to attend every meeting, but they should be present when issues affecting their departments are discussed.
Make it clear that the physician's judgment always trumps the protocol. Give proscriptive examples of when that might occur.
Make it clear why the hospital is developing protocols. Any good "futurist" consultant can make the argument for why hospitals should be moving in this direction, and a presentation to the board may result in a direct mandate that it be done.
Start with the small projects that have a reasonable chance of success. Protocols for myopia, hypothyroidism, obstetrics, and normal newborns can be done quickly and establish the legitimacy of the committee. Once the momentum is underway, move into areas such as pneumonia and osteoporosis.
Know the limits. A little pushing to get your medical staff to work on slightly more complex diseases may be needed, but know when to stop. Until technology and biometrics can provide designer drugs tailored for each patient, intuition will play an important role.
Time is of the essence
In the midst of economic and organizational change, now is the time to re-engage physicians in the process of developing and updating protocols. Waiting until there is a financial crisis is too late and could be seen as an act of desperation by the very physicians whose buy-in is critical.
Physicians today are more aware of how hospitals operate than they were a decade ago when protocols were seen as the tool of managed care companies. They are also less likely to passively resist the measures if they are more reliant upon the hospital for financial help. Done correctly, the development of protocols will be embraced by physicians and help the hospital avoid other painful decisions in the face of economic challenges.
Bryan F. Smith MHA is a senior managing consultant at Phase 2 Consulting. He can be reached atbsmith@phase2consulting.com.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
Add another victim to the poor economy. Medicare. Eight years from now, unless drastic changes are enacted in healthcare payment, the Medicare Trust Fund will go broke, according to a report released this week by the Medicare Trustees.
That's two years sooner than the same report predicted last year, thanks to declining employment, which leads to declining tax revenue for the program. A continuing trendline like that just isn't sustainable, and neither is the healthcare system as it is.
When I first started covering healthcare, a wise old soul told me once not to expect "real reform" until the Medicare Trust Fund was less than 10 years from insolvency. Well that's now.
Medicare spending is wasteful not only because of unnecessary and duplicative procedures, but because except for a few demonstration projects, it pays clinicians and hospitals only for procedures. That's like buying new engines for cars when they burn up instead of regularly changing the oil—a much cheaper alternative. You change the oil in your car because in the long run, it's much less expensive. (Oh, and there's plenty of Medicare fraud too, but that's a discussion for another day.)
In healthcare, not only are the incentives for providers all wrong, but people get to Medicare in most cases when they are 65 or older and have already developed the diseases that come from a lack of focus on wellness over a lifetime. My dad, as fit a 73-year-old as you've ever seen, was recently told by his doctor that he needed small doses of a cholesterol drug unless he was able to get his blood count down. He didn't want the medicine, so he made sacrifices in his diet and didn't have to take the drug. That saved Medicare a lot, but you can't count on most people to do that—including his son, who's on cholesterol medication now. So I include people like myself as part of the problem. The solution lies in washing down a pill every night that doesn't cost the beneficiary much, if anything, and he gets no reward for trying to stay off the drug.
Some 45.2 million people are covered by Medicare: 37.8 million aged 65 and older, and 7.4 million disabled. Meanwhile, Medicare and Medicaid pay roughly half the freight at hospitals and health systems as it is. If it's insolvent, necessary hospitals start dropping like flies. No one likes to think of such a situation as being even remotely possible in such a rich nation as the United States. But I submit that we're no longer as rich as we think we are. As a nation, we've been borrowing our way into and out of messes for generations now. And the bill is coming due not only in our financial mess but in healthcare as well.
Perhaps that's why there's a growing consensus among stakeholders that they're going to have to sacrifice something in the round of healthcare reform that seems inevitable this year in Congress.
I talked to an influential physician the other day who told me that he saw real changes coming in healthcare, not just in Medicare, because stakeholders see much more value now in being part of the solution to our healthcare cost problem than standing outside the debate and lobbing bombs at those who are trying to solve the problem. That was one of the reasons the Clinton administration failed so miserably at its healthcare reform attempt. The fact that there are fewer bomb-throwers this time around is an important first step, but we'll see how that unity of purpose is tested when we get down to details about what the President and his various task forces on healthcare reform recommend to Congress. They'll also have to answer the most important question of all: How do you fund it? Meanwhile, what are you, as a senior leader, doing to drive value in your services?
Winston Churchill once said that you can depend on Americans to do the right thing, after they've tried everything else. Well folks, we've tried just about everything else. Let's hope our political leadership and the special interests that govern Congress still know how to do the right thing—after everything else has been tried.
We'd better, if we expect Medicare to live past middle age.
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Karen Gledhill, a partner with the law firm of Robinson, Bradshaw & Hinson, says joint venture deals hospitals are striking with their physicians are still a popular choice, even in these dark economic times.
Stan Tylman does not believe the Virginia Prescription Drug Monitoring Program was hacked by a crafty computer whiz who's about to get rich through a ransom demand.
"It looks like some college kids pulling some stunts," says Tylman, the manager of the Illinois Prescription Monitoring Program.
Nonetheless, Tylman pays close attention to developments surrounding the story of the VPMP.
A hacker broke into the VPMP Web site last month and left a ransom note that said it had more than 8 million patient records and 35.5 million prescriptions. It is demanding $10 million in exchange for the records.
Tylman and Illinois' program—which Tylman coined the "Prescription Information Library," or PIL–is already tweaking its Web site security in light of the Virginia incident.
Essentially, the Illinois system has two main ports to which information is disseminated from the 14 million patient records on controlled substance prescriptions. One port is open only to a specific IP address.
"The other port we're going to be changing somewhat based on what happened in Virginia," Tylman says, "to make it even more secure."
The Illinois Bureau of Pharmacy-run system also hired private computer experts to control its server and monitor data collection. The PIL also has an internal tracking system.
"We've got a tracking system for every time someone logs on," Tylman said. "We've got electronic volumes of this stuff. It traces exactly who goes into the system."
At one point, one of the 7,000 registered users of the monitoring program–composed of doctors and pharmacists only–continuously entered the wrong password as he tried to log in. Illinois' Web tech support manager called to let him know he forgot to capitalize a letter.
In addition, Illinois also hired an outside vendor to come in and try to hack the site to detect vulnerabilities.
"We're here to help, but we have to protect the integrity of the data from the mischief makers," Tylman says. "Even I can't get into the system."
It also conducts background checks on doctors who want to register for the program, which has been online for almost a year-and-a-half. Tylman's group checks on doctors' state and medical licensing numbers to see if they're in good standing.
"Then we Google them," Tylman says, "to look up and see that they're giving us a legitimate clinic."
Then, Tylman's group will give the clinic a call and ask if "Dr. X" works there.
"And we don't sign them up until then," Tylman said.
While the potential is there for a breach of millions of patient records, like in Virginia, Tylman says the prescription monitoring program is a bargain. When it went to electronic files and did away with the massive paperwork system, the cost to operate dropped from $750,000 to $200,000 a year. Doctors and pharmacists now spend only about $10,000 to $25,000 per year to participate, down from millions, Tylman said.
Not only can it help doctors control substance abuse among patients, it also aids criminal investigations. Illinois law enforcement officials make about six to 12 requests for records per week.
But there's always the security risk, and Tylman says his group is vigilant in protecting private information of patients--especially in light of Virginia.
"Hackers can add stuff on the edge and break through these systems," Tylman says. "There are key loggers who are real slick about that. They'll try to put in software that records key strokes. We're taking steps to prevent that."
Legislation filed yesterday would create a demonstration project to test whether value-based insurance design can work in the Medicare population.
Trumpeted by employers and health plans as a way to both improve patient outcomes and lower long-term health costs, VBID lowers or eliminates copays for high-value prescriptions and treatments, such as medication for diabetes, asthma, and heart disease. The concept follows the logic that removing cost barriers will help at-risk patients follow their prescription regimens and not postpone doctors' appointments because they can't afford the care.
The bipartisan legislation was filed by Sen. Kay Bailey Hutchinson (R-TX) and Sen. Debbie Stabenow (D-MI). Hutchinson says the federal government has lagged behind the private sector in adopting VBID strategies.
"Value-based insurance design has the power to truly bend the healthcare cost curve in the right direction. By taking practical steps to lower healthcare costs and improve health, we can make insurance more affordable for all Americans. Ultimately, that is the single most important goal of healthcare reform," says Hutchinson.
VBID pilot programs have been successful in the commercial population. Pioneers in the VBID movement, Marriott and Pitney Bowes, eliminated cost sharing associated with diabetes medications and achieved positive cost and quality outcomes.
While many health insurers and employers have increased copays and created high-deductible plans as a way to lower their healthcare costs, VBID supporters say the concept is a more forward-thinking way to tackle spiraling costs.
One of the creators of VBID, A. Mark Fendrick, MD, who is co-director at the University of Michigan's Center for Value Based Insurance Design, says, "Cost containment efforts should not lead to preventable decreases in quality of care. The inclusion of value based design into the Medicare program will show that an approach that encourages the increased use of high-value medical services will produce more health for every taxpayer dollar spent."
Could VBID work in Medicare?
A recent white paper by Avalere Health and the Center for Value-Based Insurance Design suggested that the government could implement VBID in Medicare. VBID addresses both the objectives of cost containment and quality improvement by promoting fiscally responsible, clinically sensitive cost sharing, according to the white paper.
VBID advocates and policymakers think the concept could be a winner in the Medicare population. Twenty-three percent of Medicare's 26 million beneficiaries have five or more chronic conditions and account for nearly 70% of the program's spending.
Medicare beneficiaries are more likely to have chronic illness than the commercial population and more apt to take multiple medications.
Costs can create a barrier to medication compliance for beneficiaries. In fact, the Medicare Part D population takes five prescription drugs per day on average and nearly 20% of them are not able to fill a prescription or delay filling a prescription because of cost, according to the white paper.
"You have the potential to have an even greater impact [in the Medicare population] because the sicker the beneficiary is and the more you can target a value-based insurance design, the better the outcomes are likely to be," says Lisa Murphy, manager at Avalere Health in Washington, DC, and coauthor of the paper.
The researchers reviewed five options for Medicare and found that three of them can be implemented immediately with minor operational changes:
Reduce cost sharing for specific drug or drug classes
Exempt specific drugs or drug classes from 100% cost sharing in the coverage gap
Reduce cost sharing for chronic special needs plan enrollees based on the plan's target condition
The other two options that were reviewed would require policy changes, such as CMS revising its non-discrimination clause to allow for reduced cost sharing for enrollees with chronic conditions or reducing cost sharing for enrollees in Medication Therapy Management Programs.
Tanisha Carino, PhD, vice president at Avalere Health in Washington, DC, and co-author of the paper, says her research shows VBID's potential in the Medicare population. She says VBID has the potential to help make Medicare a "more prudent purchaser of healthcare that meets patient needs. These tools need to be considered in the context of health reform as they map directly into the administration's goals of improving quality and preventing complications of illness."
Leading House Republicans, apparently unhappy over being excluded from a Wednesday meeting with the president over healthcare reform and later a closed-door meeting of the House Energy and Commerce Committee to draft health reform legislation, are calling for President Barack Obama to meet with them.
On Wednesday, Obama was joined on the South Lawn of the White House by Democrats key in moving health reform through the House: Speaker Nancy Pelosi (D-CA), House Majority Leader Steny Hoyer (D-MD), House Ways and Means Committee Chairman Rep. Charlie Rangel (D-NY), House Energy and Commerce Committee Chairman Rep. Henry Waxman (D-CA) and House Education and Labor Committee Chairman Rep. George Miller (D-CA). At that session, Pelosi predicted that "legislation will be on the floor of the House before the end of July."
Missing were any Republicans. In a letter to the president, the members of the House GOP Solutions Group on Health Care Reform, headed up by Rep. Roy Blunt (R-MO), they said they wished to express their "sincere desire to work with you and find common ground on the issue of healthcare reform."
They agreed with the president on various reform objectives, such as giving individuals the right to choose the health coverage they wanted and improving lives through prevention, and wellness and disease management programs. However, they did not spell out any further proposals on coverage, but said they are currently working on "crafting a plan that will achieve the goals we share."
The nine-member group called for a meeting to discuss areas for "potential common ground on healthcare reform."
Meanwhile, Republicans said they were left out of an Energy and Commerce Committee hearing yesterday to begin drafting reform legislation. In a statement, Blunt criticized Democrats for not answering how reform initiatives would be funded, but said the members of the Health Care Solutions Group were ready to work with them.
A new survey finds that Americans want healthcare reform—they just can't decide what kind.
The written survey by the Stanford Center on Longevity, which so far has been taken by more than 2,000 people, explains different healthcare coverage strategies, their advantages and disadvantages, and asks participants to give their opinions and gauge their support.
The reform options include: changing physician and hospital payment incentives; enhanced independent review of drugs, treatments and procedures; single-payer system; state Children's Health Insurance Plan and Medicaid expansion; government-mandated plan participation; universal health vouchers with regional oversight boards; and expansion of health savings accounts.
Most survey participants called healthcare reform a high priority, but they didn't form a consensus around any of the proposals. Instead, they expressed ambivalence about the pros and cons of each idea. None of the ideas was clearly rejected either.
SCL Director Laura Carstensen says the survey findings indicate that people are willing to engage in a substantive discussion about healthcare reform and want more information about the pros and cons of reform proposals.
"It is critical that leaders engage the public in an intelligent discussion about the options for change and what they mean both for individuals and for the system broadly," Carstensen says.
"The degree of conversation we've been having about the existing problems with the system must be mirrored with conversation about solutions to those problems," she says. "There is anxiety among the public about changes to their healthcare, which necessitates building public support for proposed changes to the system if they are to be successful."
The findings also show that politics are tied to voters' reactions to various healthcare proposals. Democrats, for example, are more apt to support the expansion of access to healthcare, while Democrats, Republicans, and Independents all share strong concerns about healthcare costs.
The survey also found that: while 62% of Americans feel the healthcare system works well for them, 68% believe it does not work well for most Americans; 58% of Americans are not satisfied with cost and affordability of healthcare, but 50% are satisfied with the quality.
Oftentimes, there exists a contentious feud between supporters and objectors to specialized institutions that cater to a lucrative payer mix. Despite ongoing criticism that specialty hospitals that focus on profitable cardiac and orthopedic services would divide the haves and have-nots, a recent study found that isn't necessarily the case.
"Although the specialty hospitals initially presented challenges to general hospitals, general hospitals didn't feel the impact in their ability to care for financially vulnerable patients," says Alwyn Cassil, director of public affairs at HSC.
Some speculated that these specialty services cater to an elite payer mix, that is, low-acuity patients that can afford elective surgeries from Medicare and private insurance. They argued that general hospitals were left to take care of under- or uninsured patients, hurting their revenue. However, the study found that specialty hospitals do not pull patients, or physician specialists, from general hospitals or safety net hospitals.
About the study
Researchers surveyed three markets in Indianapolis, Phoenix, and Little Rock, Ark., between March–June 2008. Although "these three markets are not representative of all areas that have specialty hospitals," admits Cassil, the study does present interesting data about what is on the minds of leaders at general hospitals.
One survey respondent said if he were to name the top five challenges to general hospitals, specialty competition wouldn't be on that list, according to the study. General hospitals are worried more about the economy than patient or recruitment competition from than their specialized counterparts. They witnessed little change in patient acuity because of a national rise in uninsured patients overall rather than losing out to specialty services.
Government intervention
In the past decade, hospitals have elected to pursue profitable service lines with specialized care. In 2003, Congress placed an 18-month Medicare moratorium on physician self-referrals to new specialty hospitals with the goal of halting facilities in which physicians had a financial interest. However, this "paradoxical step" created disproportionate payments for existing physician-owned institutions, according to Richard Rohr, MD, MMM, FACP, director of hospitalist programs at Guthrie Healthcare System, Sayre, PA and blogger for HospitalistLeadership.com.
