Doctors at Seattle-based Harborview Medical Center call it an epidemic: more young adults are dying from trauma injuries than AIDS and stroke combined. But with all the charity care and the economic recession, trauma centers around the country, including Harborview, are now suffering themselves. In the past eight years, 20 hospitals have closed their trauma centers because they cannot afford the cost of specialized and often charity care.
Coastside Family Medical Center, a medical clinic in Half Moon Bay, CA, closed recently with no notice. Open for nearly 25 years, it served 8,000 people. Because Coastside cared for the insured and uninsured, it did not qualify for a federal program that offers significant reimbursements to clinics serving the poor. Of Coastside's 8,000 patients, 6,000 had private insurance, with the remainder uninsured or receiving Medicare or Medi-Cal. Rising costs of healthcare, coupled with a drop in donations and grants, finally did the center in.
Missouri Gov. Jay Nixon is shifting his hopes for expanding government healthcare to the Senate after the House passed a budget containing no money for it. The Senate Appropriations Committee chairman says there is considerable support in his chamber for expanding health coverage, either through Nixon's plan or a private-sector alternative. The Republican-led House approved a $22.8 billion operating budget for next year after a multi-day debate that focused on how much the state can afford to spend. A key point of disagreement is Nixon's proposal to spend $145 million to expand Medicaid health coverage to an estimated 35,000 low-income parents.
Scott Raynes, MA, MBA, has resigned his position as president and Chief Executive Officer of Springfield, TN-based NorthCrest Medical Center. Raynes has accepted a position with WakeMed Health and Hospitals, a private, not-for-profit healthcare organization based in Raleigh, NC. His role will be as senior vice president and administrator of the health system's hospital in Cary, NC.
The Senate Finance Committee has scheduled a confirmation hearing on April 2 for Gov. Kathleen Sebelius of Kansas, who is President Obama's nominee for secretary of Health and Human Services. The withdrawal of Tom Daschle as Obama's original nominee for health secretary was one of the first major setbacks for the new administration, and the delay in confirming Governor Sebelius to the post has only heightened concerns that Obama's healthcare agenda has been slowed by personnel issues.
Every physician office needs a compliance plan—a written document that outlines proper policies and procedures for coding, billing, and managing other regulations that apply to physician practices. Ideally, your compliance plan will keep you out of hot water with the Office of Inspector General (OIG) and health plan or government auditors.
But should you be accused of noncompliance, simply having a written plan protects a practice from penalties and other damages that can be levied against it in the event of incidents without intent. Not developing and implementing a compliance plan essentially removes those protections.
Although most facilities have such a plan, some are slow to adjust their policies based on changes within the practice. Others simply fail to follow procedures defined within their plan. It's crucial to keep compliance a priority, however, to avoid government penalties and withheld reimbursement.
"The OIG Work Plan is the government crystal ball," says Curtis J. Udell, CPAR, CPC, senior advisor at Health Care Advisors, Inc., in Annandale, VA.
The Work Plan outlines seven general guidelines for compliance plan development and implementation:
1. Conduct internal monitoring and auditing.
2. Establish policies and procedures that include an examination of risk areas specific to your practice, such as those relating to coding and billing; reasonable and necessary services; documentation; and improper inducements, kickbacks, and self-referrals.
3. Designate a compliance officer or contact to monitor compliance efforts and enforce practice standards.
4. Conduct compliance training, particularly in regard to coding and billing.
5. Respond to and investigate detected violations, disclose any such incidents to the appropriate government agencies, and develop corrective action initiatives.
6. Keep the lines of communication open via discussions at staff meetings or community bulletin boards. Janet Burch, administrator at Pikes Peak Nephrology Associates, PC, a nine-provider practice in Colorado Springs, CO, says to delegate some of the development and implementation work to staff members, making the process a team effort. "It allows everyone to take more ownership in the practice," Burch says.
7. Publicize guidelines and enforce disciplinary standards.
These seven elements are just a starting point for practices' compliance efforts, says Udell. "It must be an active part of practice operations."
This article was adapted from the March 2009 issue ofThe Doctor's Office, a HealthLeaders Media publication.
Trust is not easy to come by these days. Yet physicians, as a whole, still enjoy a level of trust and credibility that few authority figures can boast. Particularly when it comes to healthcare reform, voters view physicians as being on their side.
That can change and change quickly, however. It is becoming increasingly difficult to read the news these days without stumbling across a story about medical research tainted by drug industry ties, and if anything can tarnish physicians' public image, it is a few highly-publicized and ill-timed cases of corruption and fraudulent research.
A few weeks ago, it was Scott Reuben, a well-known anesthesiologist at Baystate Medical Center in Springfield, MA, who made headlines when allegations surfaced that he may have fabricated results—and even used fictitious patients—in at least 21 published papers over a 13-year period showing positive data for drugs produced by Pfizer, Inc. You may not be surprised to learn that Pfizer had given Reuben five research grants and made him a member of its speakers' bureau.
More recently Joseph Biederman, a Harvard child psychiatrist, has come under fire for allegedly telling Johnson & Johnson that studies of its drugs for children would yield positive results, before he administered the tests.
Perhaps the biggest story has been the spat between the Journal of the American Medial Association and Jonathan Leo, an associate professor of neuro-anatomy at Lincoln Memorial University in Tennessee. In October 2008, Leo uncovered an unreported financial conflict of interest, as well as questionable results, in a study of depression drug Lexpro that was published in JAMA.
Leo reportedly alerted JAMA to the conflict of interest, and after four months without a response, took his criticism public by publishing a letter about the study in the British Medical Journal. That got JAMA's attention. According to the Wall Street Journal, JAMA Editor-in-Chief Catherine DeAngelis called Leo a "nothing and a nobody," and told him, "You are banned from JAMA for life. You will be sorry. Your school will be sorry. Your students will be sorry."
JAMA claims the quotes were misreported, but their follow-up actions suggest a certain tone deafness to the real problem. The journal effectively implemented a gag order and has instructed anyone who unearths possible financial conflicts not to go public until editors have completed an investigation.
JAMA would have been better off going in the other direction and increasing transparency to avoid the impression of a cover-up, or perhaps advocating for much stricter restrictions on pharmaceutical gifts to physicians. Instead, they are responding as if this is only a public relations problem.
But the poison runs much deeper than that.
If you think the public seemed on the verge of taking up pitchforks and torches in outrage at AIG bonuses, imagine what would happen if one of these fraudulent studies led physicians to prescribe a drug with potential lethal consequences. Consider the media frenzy and public outcry in this zeitgeist if it were revealed that a physician ignored the potential warning signs after earning six figures from that same drugmaker.
The AIG debacle wasn't just about money—it was about a lack of accountability and a willingness to profit at the expense of the general public. When JAMA attempts to silence critics, it comes across unapologetic and unaccountable. Those elements also bubbled up in a revealing deposition in the Biederman case when a prosecutor asked who outranked him as a full professor at Harvard, and he responded simply: "God."
It's not just patients who should be angry at these shady relationships and the permissive environment that enables them. Physicians rely on this type of research to make treatment decisions, and hospitals and other institutions put their reputations on the line when something goes wrong.
Certainly, most physician researchers' hands are clean, and it is unfair to let a few cases soil the reputation of an entire industry. But as we saw in the financial sector, when people begin taking up torches and pitchforks and looking for justice, they don't tend to be very discriminating in their targets.
Elyas Bakhtiari is a managing editor with HealthLeaders Media. He can be reached at ebakhtiari@healthleadersmedia.com.
Note: You can sign up to receive HealthLeaders Media PhysicianLeaders, a free weekly e-newsletter that features the top physician business headlines of the week from leading news sources.
An Italian doctor completed a brain operation despite having a heart attack after realizing his patient would never recover if he stopped the surgery. Surgeon Claudio Vitale started feeling pains in his chest half way through the operation but refused to stop despite his team's urging and the pain worsening. After finishing the surgery, the doctor had an angioplasty operation to treat his attack.
Comparative effectiveness research has been a controversial topic since the Obama administration proposed $1.1 billion in CER funding in the economic stimulus package. Physician-blogger Kevin Pho provides his opinion in USA Today, arguing that physicians often make decisions based on the latest, but not necessarily the best, treatment options, and CER can help them make more informed decisions.
The term collaborative isn't often used to describe the provider-payer relationship, and the quality and patient safety arena traditionally has been no exception. But if some fledgling initiatives deliver results on the quality improvement front, that dynamic could be changing.
Blue Cross Blue Shield of Massachusetts has signed four provider organizations to its "Alternative Quality Contract," a five-year pact that offers significant payment incentives tied to a long list of quality measures. The providers include two hospitals—Mount Auburn Hospital in Cambridge, MA, and Tufts Medical Center in Boston—and two physician groups—Mount Auburn's affiliated physician group Mount Auburn Cambridge Independent Practice Association, and Hampden County Physician Associates in Springfield, MA.
"We view the contract as one more step in the direction of aligning payers and providers in a way that helps the patient," says Susan Abookire, MD, MPH, chair of the department of quality and patient safety at Mount Auburn, a 203-staffed-bed teaching hospital affiliated with Harvard University Medical School. "Traditionally we've seen some pay-for-performance arrangements that added small quality bonuses, but this is a dramatic shift to align the bulk of payment with quality."
The AQC marks a new twist on an old reimbursement model: capitation. Under the contract, providers receive a fixed per-patient payment adjusted for health status and inflation, rather than a fee-for-service arrangement. Additionally, providers can increase their total payment by up to 10% by hitting inpatient and ambulatory performance targets tied to a set of process, outcomes, and patient experience measures.
But does the contract genuinely differ from capitation? A November 2008 BCBSMA white paper offers three reasons why it does:
Coupling the fixed payment with performance measures helps safe-guard against undertreatment.
The fixed payment budget is both based on actual costs that consider the relative morbidity of patients and adjusted for inflation annually.
Because the AQC includes a global payment for all services received by a BCBSMA member, costs are lowered and care is improved when a physician spends extra time with a patient that helps avoid unnecessary hospitalization.
"For organizations that choose the AQC, the global budgets are built on historical claims trends and costs, including any existing patterns of patients receiving care from outside specialists," says John Fallon, MD, chief physician executive at BCBSMA.
Abookire says the AQC is actually "inclusive of the capitation model," but the amount of reimbursement tied to quality makes it unique. "If you were in a fully capitated model, in theory you could be incentivized to give less care. With fee for service, you're incentivized to give more care. But what you really want to do is give the right amount of care."
School days
Beyond the notion of offering caregivers increased payment incentives, BCBSMA and provider organizations have also been addressing the issue of quality and patient safety through another avenue: hospital board education. At the end of 2007, BCBSMA launched a trustee education program aimed at encouraging trustees to embrace their roles as quality champions.
BCBSMA approached the Massachusetts Hospital Association to partner on the project after deciding that "individual boardrooms might not be as receptive," Shonkoff says. Nevertheless, BCBSMA did encounter resistance; some hospital leaders "took the posture that they were far along in this work and that the course would be too elementary," she says.
But that initial skepticism has "pretty much dissipated," Shonkoff says. The curriculum involves a six-hour course in a retreat setting and focuses on six areas—mission, strategy, culture, performance, leadership, and resource allocation. The program aims to spark the creation of hospital quality improvement plans to eliminate performance gaps. Boards also have a financial incentive to create such plans; hospitals can earn additional money if they adopt quality improvement plans that address a certain number of quality gaps, she says.
Twenty-five hospitals have completed the course, Shonkoff says. Additionally, BCBSMA in February launched the Trustee Advantage program, which awards five $50,000 grants to hospital boards (matched by $25,000 from each hospital) to engage a quality and governance "coach" to assist with improvement efforts.
Obstacles to overcome
Creating a provider-payer collaboration to improve quality is not without hurdles, however. Payers must align initiatives with what providers believe is genuinely important. BCBSMA enlisted input from multiple provider organizations to help craft the trustee curriculum, Shonkoff says. "We had an advisory session with hospital leaders, and they said they wanted to learn more about best practices and have individual coaching." For providers, the ubiquitous theme of physician support certainly applies to quality collaborations, Abookire says. But another important consideration for hospital leaders considering an initiative like the Alternative Quality Contract is their willingness to put their financial welfare in their own hands.
"Organizations without the existing infrastructure to achieve the quality goals would be at risk," Abookire says. "An organization needs to work collaboratively with its physician group, because we're at risk together. Sharing the risk in the Alternative Quality Contract can develop that relationship, because everyone has the same goal. That may be a novel concept for some hospitals."
Financial risk and alignment aside, some measure of momentum on both sides of the reimbursement equation appears to be building for providers and payers to work together more closely. "E-prescribing, computerized physician order entry, and patient safety studies are all initiatives that put into practice a system that will deliver the right care at the right time. In order for these programs to be successful, all partners need to work together," Fallon says.
Creating significant quality partnerships may come down to changing a longstanding provider-payer dynamic, Abookire says. "The dynamic traditionally does pit one against the other, because if the dynamic is only about money, the dynamic almost by definition is a win-lose," she says. "I think there are many folks endeavoring to align incentives around quality, but [the AQC] takes it to another level. Is it a harbinger of things to come? I'm an optimist—if we do it well, it could change the dynamic so that everybody wins."
