There was a recent spat over how the Journal of the American Medical Association handled a case in which the author of a study it published on antidepressant use in stroke patients failed to note he had a financial relationship with the drug company whose product was studied. Now the author of that 2008 study, University of Iowa psychiatrist Robert Robinson, is firing back at his critics in a letter published online in the British Medical Journal.
When President Obama was on the campaign trail, he pushed the idea of giving consumers the chance to choose among both private and publicly sponsored health-insurance options. One question is whether the new public plan would pay doctors at the same rates that Medicare does—rates many doctors feel are too low. In a media briefing hosted by the Kaiser Family Foundation, Nancy-Ann DeParle, who's running the new White House Office of Health Reform, was asked for her own definition of the term "public health insurance." Here, the Wall Street Journal Health Blog provides her answer.
The nation's pharmaceutical makers spent more than $2.9 million on Vermont's doctors, hospitals, and universities to market their products in the last fiscal year, according to a report issued by the state attorney general's office. The report shows 78 companies spent the money in the year ending July 1, 2008. By law, the companies have to report their spending on consulting and speakers' fees, travel expenses, gifts and other payments to or for physicians, hospitals, universities, and others authorized to prescribe drugs.
The next time you meet with your hospital's emergency planning coordinators, ask them whether the facility is ready to stand in as the corner drug store or local diner during a community-wide catastrophe.
These considerations should get a CEO's attention, says Joseph Cappiello, chairman of Cappiello & Associates in Elmhurst, IL, and the former vice president of accreditation field operations at The Joint Commission.
During a community disaster, the public may look to a hospital for refuge, so CEOs and hospital emergency management coordinators would be wise to include public services in their planning, Cappiello says.
Such was the experience at Heywood Hospital in Gardner, MA, and Muhlenberg Community Hospital in Greenville, KY, during ice storms in those regions in December 2008 and January 2009.
The storms knocked out power across widespread areas. Generally, in such situations hospitals receive priority assistance from utility companies to get power back up, which leads to medical centers becoming sought-after sites for those in the general public who need electricity or services provided by electricity, safety managers at both sites said.
For example, until every local drug store and retail chain pharmacy gets its power back-or community responders set up temporary pharmacies elsewhere-hospitals must prepare to fill prescriptions for folks who need their medications, said Scott Janssens, RRT, MBA, CMRP, director of materials management and safety for Heywood Hospital.
Also, hospitals should brace for booming business at their cafeterias during power outages. Muhlenberg Community Hospital's cafeteria was one of the few working restaurants in town in the aftermath of the storm, said Martin Wheatley, director of engineering.
CEOs should confirm that hospital emergency operations plans anticipate serving:
Additional employee meals if added workers have been called in during a disaster response
Meals for community residents who can't get food anywhere else if grocery stores and eateries are without power or water
Also, Muhlenberg Community Hospital provided temporary housing for some staff members who had no means of getting home or who elected to put in as much overtime as needed.
"A lot of people [either] stayed or couldn't leave," Wheatley said. "We put them up in extra rooms we weren't using."
Heywood Hospital stayed on generator power for 48 hours during the December ice storm. However, because the rest of the small city and surrounding area remained without power for much longer, Heywood Hospital extended its emergency operations to 105 hours total, Janssens said.
A leading proponent of creating a public insurance option recently released a 27-page report that serves as a blueprint for how the public plan could compete on a "level playing field" with private insurers. But another recent study suggested a public option could have a disastrous impact on private health insurers and cause physician payments to plummet.
Backed by President Barack Obama, Health and Human Services nominee Kathleen Sebelius, and Senate Finance Committee Chairman Max Baucus, the public insurance option would create a competing public plan that would allow Americans to choose between public and private insurance plans.
Hacker says a public option would cut costs by providing direct competition with insurers. Public insurance is better at containing costs through lower administrative costs and greater bargaining power than private plans, he says.
"What I'm arguing for is a system in which public and private plans with their strengths and weaknesses could coexist side by side so that all Americans, not just the elderly or the poor, have access to the distinctive strengths of a public health insurance plan as well as the strengths of private plans," says Hacker.
John Sheils, senior vice president at The Lewin Group, a healthcare policy research and management consulting firm owned by Ingenix, which is a wholly-owned subsidiary of UnitedHealth Group, says one public insurance scenario could push 70% of private insurance members into public plans. Because proponents have not created a definitive public insurance plan, The Lewin Group looked at different public options, including one that would allow all private insurance members to switch to a public plan as well as an option that would allow only small employers, individuals, and the self-employed access to a public plan.
Private insurers could lose 70% of its business if the former option is implemented, which could force private insurers to cut a similar percentage of its workforce, he says. Under that option, "private insurance would have trouble surviving," says Sheils. "Maybe there would be some consolidations, but I'm not sure if private health insurance plans would be the most valuable investment in the world at that point."
If the public plan was available to all employees and the government paid at Medicare levels, The Lewin Group estimated that 131 million Americans would enroll in the public plan with 119 million coming from private health plans. This would mean an exodus of two-thirds of currently enrolled private plan members.
If the public option was limited to only small employers, individuals, and the self-employed, The Lewin Group estimated that the public plan would include nearly 43 million Americans with 32 million coming from private insurance.
Because the feds have also not offered a payment structure for the public insurance plan, The Lewin Group evaluated the impact of two possible payment routes: the same payment level as Medicare and paying the same amount as private insurers.
Sheils says that if the feds decide to use Medicare payment levels, public option premiums would be 30% less than comparable private coverage. This would mean a savings of about $200 per family per month on average.
Those lower premiums would woo many people with employer-based coverage to the public plan. However, if the public option paid at private insurance levels, which would lead to higher premiums, fewer insured Americans would be tempted to a private plan, according to The Lewin Group.
The Lewin Group also found that hospitals and physicians would see less money if a public option is open to all employer-based members. Hospitals would actually benefit financially if the public option is limited to small employers, self-insured, and individual plan members because uncompensated care cost savings would more than offset lower payments.
Physicians, on the other hand, would have more patients and get paid less under Medicare level funding. Despite potentially lower payments in a public plan, many doctors support the option because it would cut down on administrative costs. Their offices would not have to perform as much utilization management or review, says Sheils.
"That's a very expensive thing for physicians to comply with. It takes up physician time. They usually employ a nurse to handle a lot of that. It's an expense and a headache that a lot of them feel they could do without and would be willing to live with the lower payment levels," he says.
Hacker's proposal would build on Medicare's administrative infrastructure and basic coverage framework. One difference is that the government would make a self-sustaining public insurance option that would be separate from Medicare, says Hacker, who has written extensively about the public insurance option and the failures of other reform plans.
Other healthcare reform proposals might expand coverage, such as individual and employer mandates, but they do not contain costs, he says.
Hacker says a public option is needed because the current healthcare system does not provide "healthy competition." Having a public insurance option competing side-by-side with private insurers would allow individuals to choose between the plans based on their strengths and provide a safety net so Americans can stay insured.
A private insurer's strengths include integrated systems and care management programs, Hacker says, while a public option's strengths would be in the areas of stability, transparency, affordable premiums, and provider access. "These are hallmarks of public plans that private plans have inherent difficulties providing," says Hacker.
In order to establish a workable public-private competition, Hacker says a healthcare system needs three "Rs":
Rules that would make both types of plans work on a level playing field, such as offering subsidies for both plans to care for low-income and middle-class Americans
Risk adjustment that protects plans from being at a disadvantage because they enroll people who are not as healthy as their competition
Regional pricing that allows plans to compete on a level playing field within regions
Hacker says a public option would be built on Medicare's foundation, but suggests that the nation needs to broaden the benefit package, focus on value and efficiency, increase payments to primary care physicians, and move to a bundled payment model.
Another supporter of the public insurance option, Institute for America's Future co-director Roger Hickey, says other attempts at major healthcare reform, most notably in Massachusetts, simply "subsidize people to buy private insurance" and don't tackle spiraling healthcare costs.
"[The Massachusetts model] simply expands the number of people who are able to buy private insurance. Some people are under the impression by simply mandating individuals that buying insurance means comprehensive coverage. What it's more likely to mean is either really lousy healthcare plans or a very unaffordable healthcare plan for many people and a lot of resentment if you don't have the structures in place to assure good health insurance at decent prices," says Hickey.
Physicians as leaders are often like fish out of water. While they are typically regarded highly by society, most physicians have no leadership experience whatsoever. Physicians are among the most highly educated groups in our society, but as they progress from high school to college and from medical school to specialty training, the breadth of their education markedly narrows.
In fact, most physicians are students well into their 30s before they finally go out into the world to practice a specialty. Once they begin to practice, they often work in an environment that allows them to focus on what they do best—practice medicine.
Hospitals, on the other hand, are run mostly by leaders who have either MBAs or degrees in hospital administration. They understand hospital finances and hotel management, but they typically do not understand clinical medicine. Because of this obvious gap, most hospitals delegate clinical quality and physician credentialing to the medical staff. Furthermore, hospital presidents know that physician-generated admissions and utilization of resources by physicians are important to their financial stability. They need and depend upon the physicians.
However, they typically hire physicians and then place them in leadership positions such as department chief, medical director, etc., and this is where the problem begins. Physicians lack the proper training for some of these roles. They do, however, bring both strengths and weaknesses to their leadership positions, and physicians who perform well as leaders are a highly valued treasure for any healthcare organization.
Physicians becoming leaders
For the physician, leadership can be a lonely scenario at times. Upon assuming a position of leadership, there is inevitably the belief among colleagues that he or she is no longer one of them and is now an "administrator."
This shift is not unique to physicians. It is a difficult but necessary move on the leadership pipeline, but for the physician leader, it doesn't stop there. To add to the pain, the hospital's senior management team often does not regard the physician as a true executive, either. This is due to the lack of formal business education or the lack of leadership experience. So the physician lives in a sort of no-man's land.
Healthcare leaders who are not physicians have typically been groomed for leadership for many years, but the physician has been groomed to provide quality healthcare. There are often major gaps between what the physician is and where he or she needs to be to execute the business of healthcare effectively.
The leadership gaps
Physicians in general are used to being totally responsible for their patients' care. They may consult with specialist colleagues, but they alone control the aspects of their patients' care. As leaders, this skill does not serve them well. They often find delegation of duties very difficult and try to do everything themselves. Delegation of responsibilities and allowing the delegate to perform independently without hovering is an art that must be learned and developed.
Physicians are also accustomed to being obeyed, to working independently, and to being the center of attention. A doctor gives orders and expects absolute deference and immediate action. This may work in the operating room where the environment can be urgent and tense. It does not work, however, when leading others outside of the operating room.
As a healthcare leader, influencing becomes a critical skill. The physician leader must learn to effectively state a case and still be able to support the management team if an alternative course of action is chosen. He or she must learn the art of give-and-take, negotiating with other team members. Ultimately, the physician leader must learn to participate in and build effective and cohesive teams.
Another peculiar characteristic is that physicians are often in "transmit" mode. This is a result of their training, which is odd because it doesn't always work that well in the practice of medicine. In fact, many physicians are not even that good at listening to their patients. Developing good listening skills is crucial, as effective communication requires both transmitting and receiving.
The physician leader has to learn that when attending a meeting, it may be better to hear others' opinions around the table before speaking. This gives the physician time to be clear about what he or she wants to say and then to be more flexible in presenting ideas. Communication skills (verbal, writing, and listening) are crucial for effectiveness both as a physician and a leader.
An issue that is not often discussed is that many physicians have personality or character issues due to a prolonged period as a student. Many do not start their careers until their early 30s. They work long hours and study in their off-hours. They have little time to develop social skills. Their social skills often stop developing when they enter medical school. By the time they are asked by the healthcare organization to take a leadership role, they will have bridged some of the social skill gap, but it is very likely that there are still some socialization skills that are significantly lagging.
Conflict management is a skill that the physician leader may have practiced with patients but more often than not, the physician speaks and the patient listens with little opportunity for conflict. However, the need for this skill is unavoidable in any leadership role. The physician leader must be able to deal effectively with diverse personalities and cultural backgrounds. He or she must be able to find the root cause of the disagreements and reach compromises that will be accepted by all. To do so, the physician leader must demonstrate that he or she is impartial, trustworthy, and capable of resolving the conflict.
In today's complicated healthcare environment, physicians need more than clinical and leadership skills—they also need business development skills. Physician leaders must work to gain the trust and referrals of the primary care doctors who are only loosely connected to the hospital and also use business development skills to recruit other physicians.
Finally, the physician leader must be the advocate for the highest quality of patient care for both the individual physician and the medical staff. He or she must be able to critique care with other physicians without being punitive, unless there are chronic problems. There must be an understanding of evidence-based medicine and he or she must be able to evaluate the quality of the measurement statistics that are provided. Improving quality of care and evaluating the need for new technology are probably the most important aspects of the physician leaders' job, especially as pay-for-performance becomes more prevalent.
Physician leadership strengths
Physicians do, on the other hand, possess some very positive characteristics that they bring to the leadership table. They typically have high self-confidence and are accustomed to making tough, even life or death, decisions. These decision-making skills are a great benefit to any leadership role. At Executive Development Associates, working with executives across medium and large organizations, we have found that this is often an area of development for even the most senior members of the leadership ranks.
When the physician is widely respected for clinical skills, he or she will be even more effective with other members of the medical staff. Doctors have a unique respect for other doctors, and no matter how great a leader an administrator becomes, without the clinical credentials there will always be a gap between the administrator and the medical staff.
Regardless of their grandiose mission statements, hospital missions are primarily to care for ill patients and restore them to good health. Physician leaders understand what needs to be done clinically. They are able to prioritize the development of clinical services and requirements for new technology and typically they are also very adept at alerting the management team of the clinical consequences of business decisions.
Physicians also use time efficiently. They are usually more interested in conserving time than in processing ideas. This can be a strength and a weakness for the physician who is operating in a leadership capacity. Maneuvering through political minutia can sometimes take more time than a physician leader is willing to give.
Acquiring the necessary skills
Fortunately, physicians are accustomed to continuing education, so taking classes and working to learn leadership skills is not a barrier. The physician leader will need additional leadership skills to be a contributing member of the management team.
Ultimately, physician leaders must understand the gap in their skills and be willing to invest in their leadership growth and development with such activities as:
360-degree surveys feedback to identify skill gaps
One-on-one coaching
Conferences
Development programs
Formal degrees
Leadership development takes an investment in time and effort with significant trial and error along the way. The physician leader role is rather unique and is best served with a combination of learning and development opportunities that are tailored to meet the individual physician's circumstances, ultimately creating physicians who are excellent leaders as well as excellent clinicians.
Charles Saunders, MD, is vice chair of the St. Luke's Allentown Hospital Board of Governors and serves as a trustee of the St. Luke's Health Network Board in Bethlehem, PA. Bonnie Hagemann is CEO of Executive Development Associates, Inc.
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Medicare is underpaying physicians between 10% and 25% in 175 higher-cost counties across the nation, creating a "public health crisis" in which too few doctors accept the federal program, resulting in jeopardized patient care.
That's the claim in the latest volley of a California class action lawsuit against the Department of Health and Human Services. The claim argues for a change in an allegedly antiqued formula affecting thousands of physicians in at least seven California counties, and many more in the other 168 that would like to join in. First filed in 2007, and rejected last year, the case is now under appeal.
"Between 2001 and 2007, Medicare underpaid these providers (nationally) nearly $2.5 billion," says Dario de Ghetaldi, the Millbrae, CA, attorney who filed the case. In Santa Cruz County, for example, doctors receive 25% less for taking care of a Medicare patient under Part B than their counterparts in neighboring San Mateo and Santa Clara counties, despite similar costs of practicing. As a result, many doctors are just saying no to any new Medicare patients, the claim says.
For all seven counties in the state involved in the case (Santa Cruz, Sonoma, San Diego, Marin, Santa Barbara, San Luis Obispo, and Monterey), the amount is about $340 million in underpayments, the most of any other state, de Ghetaldi said.
California is closely followed by Texas with $246 million; North Carolina, $176 million; Minnesota, $164 million; Ohio, $159 million (all in Cuyahoga County); Florida, $150 million; Virginia, $126 million; Wisconsin, $111; Colorado, $83; and Massachusetts, $81 million, according to the lawsuit.
Ellen Griffith, spokeswoman for CMS, declined to comment on pending litigation. But she said changing geographic adjustments cannot change the size of the total Medicare reimbursement pie. "If we give these counties more, we'd have to give other counties less," she said.
The disparity evolved because federal physician reimbursement formulas are based on averaged costs for each metropolitan statistical area (MSA) known as the Geographic Practice Cost Index, or GPCI. The complex formula is much different than that for hospitals.
It's based on the regional average cost for a doctor to rent an office space, employ staff, buy supplies, and purchase malpractice insurance.
In California the federal formula established MSA 99, a "rural" region with 47 counties, such as Imperial, Modoc, or Inyo. But it also includes the claimants: Sonoma, Santa Barbara, Santa Cruz, San Luis Obispo, Marin, Monterey, and San Diego counties, whose populations and costs have grown exponentially, de Ghetaldi claims.
San Diego County alone wants back an underpayment of $155 million, nearly half the state's alleged underpayment.
The lawsuit wants all of the county health systems that employ physicians be reimbursed for underpayments they received, and that all physicians who were underpaid be retroactively reimbursed.
Federal officials acknowledge the disparity, but are reluctant to change the formula because it could mean reducing payments to doctors in many rural areas, where physician shortages are well documented, de Ghetaldi said.
For example, a report from the General Accounting Office in June 29, 2007 was titled, "Payments for Variation in Practice Costs Should Be Revised" using an approach "uniformly applied to all states," and based "on the most current data."
This Thursday, April 16, de Ghetaldi's brother Larry de Ghetaldi, MD, an emergency room physician in Santa Cruz, as well as representatives of the California Medical Association, will join representatives of House Speaker Nancy Pelosi and California Congressman Sam Farr in a visit to Washington to argue for quicker remedies. The lawsuit may drag on, further jeopardizing Medicare patients' care, de Ghetaldi said.
De Ghetaldi's original lawsuit in 2007 was rejected by the U.S. District Court in San Francisco, in part on grounds that the case was filed on behalf of counties, not individual doctors. Plaintiffs must be individuals, the court ruled.
DeGhetaldi said he initially tried to get physician groups to put their names on court documents, but many balked. "All the ones we talked to, before we filed the claims, were afraid of retaliatory audits by Medicare," he said. Since then, he said, he found other legal arguments and those are in his appeal, which he argued before the Ninth Circuit Court of Appeals in San Francisco on April 13.
The hearing date was expedited, de Ghetaldi said, because the court accepted the argument that the situation has caused a "public health crisis." Too many physicians, especially in important specialties, are unwilling to take Medicare patients in key counties throughout California because of the disparity, he said.
Not only are these doctors financially affected by the unfairly low reimbursements, "that failure has resulted in a widespread public health crisis as the number of physicians in the affected counties who still provide services to Medicare beneficiaries has diminished dramatically," de Ghetaldi wrote in his appeal.
Such a situation has been well documented in Santa Cruz County, where newspaper reports say seniors must get care at Planned Parenthood or the emergency room because there are so few doctors who still accept Medicare.
Sen. Ted Kennedy says he won't support a healthcare reform bill unless it includes provisions to help Americans pay for long-term care. Kennedy backs a plan that would create a new long-term care fund that would be funded through a $30 per-month deduction from working adults' paychecks.
TriState Health Partners, Inc.'s clinical integration program cleared a major hurdle this week when the FTC issued an advisory opinion that the innovative program does not pose an antitrust threat.
"This favorable advisory opinion means we now can move forward with a comprehensive health management program that will make patients healthier and healthcare more affordable," says Robert J. Cirincione, MD, CMO of Hagerstown, MD-based TriState, a physician-hospital organization owned by 212 physicians and the Washington County (MD) Hospital.
The FTC's Bureau of Competition told TriState that the proposed cooperation among doctors and a hospital at the organization, "while still in the early stages of development in some respects, appears to have the potential to create substantial integration among its participants, with the potential to produce significant efficiencies, including both improved quality and more cost-effective care."
TriState is the third organization in the country to receive a favorable FTC advisory opinion for its clinical integration program. Cirincione says TriState showed the FTC that its program is pro-competitive because physicians are collaborating to produce a superior system for quality care though cooperation, investment in technology, and value-based purchasing and performance incentives. "Our program is designed by the very people who know the patients and their needs best—their doctors" Cirincione says.
The FTC told TriState that its joint negotiation of contracts, including price terms, with payers on behalf of its physician members appears to be "subordinate and reasonably related to TriState's members' . . . integration through the proposed program, and appears reasonably necessary to achieve the potential efficiencies of that program." As a result, the FTC says, the price agreements and joint contracting would be evaluated under the antitrust rule of reason, rather than being summarily condemned as per se illegal price fixing.
The program will provide members access to electronic health records, develop evidence-based quality indicators to ensure achievement of measurable quality improvement, and enhance case and pharmacy benefits management that can control costs. It also will allow TriState to contract on behalf of its 212 physician members with self-insured and fully insured employers.
If the program is operated as proposed, the FTC says, TriState "is unlikely to be able to attain, increase, or exercise market power for itself or its participants as a result of implementing the proposed program." However, the FTC warned that any evidence of exercise of market power or other anticompetitive activities by TriState could result in the revocation of the opinion.
CMS continued its efforts this week to educate healthcare providers on the permanent Recovery Audit Contractor program with an Open Door Forum call for Medicare Part B providers on April 14. A similar call for Part A providers was held on April 8.
Providers may wish to listen to the Open Door Forum calls, including the helpful Q&A portion of the program—even those who feel as though they are experts on the RAC program may find they learn new information. For instance, consider the following points discussed during the April 14 call:
On medical record request limits: If your medical record request limit is per National Provider Identifier, listen up. The record request limit is based on your group NPIs, not the number of NPIs assigned to your individual physicians. "This could be an issue," explains Nancy Beckley, MS, MBA, CHC, of Certified Healthcare Compliance at Bloomingdale Consulting Group, Inc., in Brandon, FL. "An 18-member physician practice group that has a group NPI could expect requests of 50 medical records every 45 days, whereas if this same medical group issues a different group NPI to each of its three practice locations (each of which have six doctors), the physician practice group could have up to 30 medical records requested for each of the three groups—for a total of 90 medical records every 45 days."
On line-item billing: For a claim containing multiple CPT codes for the same date of service, each code (i.e., procedure) constitutes an item that RACs can review. Beckley believes this may come as a surprise to many providers considering a visit (which could encompass several CPT codes) as a claim for a date of service.
On contingency fees: RACs receive the same contingency fee regardless of whether they identify overpayments or underpayments.
On submitting electronic claims: The RACs currently aren't set up to receive electronic data interchange—nor will they be for some time. For now, submit paper claims (via fax) or send images of electronic medical records via CD or DVD.
If you prefer to find out more about the RAC program during a live outreach session, you may find CMS is hosting an educational session in your neck of the woods. CMS is partnering with state hospital associations, state medical societies, and CMS regional offices to roll out these meetings. Check out CMS' recently updated RAC education and outreach schedule for information on available sessions. The schedule also contains information regarding which types of healthcare provider (e.g., hospitals, physicians, skilled nursing facilities, etc.) should attend the various sessions, as well as who will provide the presentations during the sessions. CMS will continue to update the RAC schedule as new sessions become available. (View the most recent version on the CMS Web site.)
If you are in a blue state, you will start seeing outreach sessions in your area beginning in August. If you are a yellow or green state, you should see sessions in your area soon. If you are a yellow or green state and believe CMS has no outreach sessions applicable to your organization in your area, e-mail CMS.
CMS acknowledged during the April 14 RAC Open Door Forum call's Q&A portion that hospital associations and medical societies hosting the provider outreach sessions may have limited participation to "members only," leaving nonhospital or nonphysician providers (e.g., physical therapy clinics or DME providers) without an opportunity to attend a session, says Beckley. If you find this to be the case, in addition to e-mailing CMS with your concerns, you should also consider contacting your national trade organization. Express your concerns to organizations such as the American Physical Therapy Association, the National Association of Rehab Providers and Agencies, or the National Association for Homecare and Hospice, Beckley suggests.
CMS also plans to provide an outreach presentation on its Web site for providers unable to attend the live sessions.
