A federal trial that begins Dec. 7 in Miami could effect the medical care of 1.4 million Florida children. In a class-action lawsuit filed four years ago, disabled, or impoverished children whose healthcare bill is paid for by Medicaid claim they must endure long waits or long drives to find doctors or dentists who accept the insurance plan. They argue their medical care is at times so poor that it violates federal law.
Firms that supply temporary nurses to the nation's hospitals are taking perilous shortcuts in their screening and supervision, sometimes putting seriously ill patients in the hands of incompetent or impaired caregivers, the Los Angeles Times reports. Emboldened by a chronic nursing shortage and scant regulation, the firms vie for their share of the $4-billion industry. An investigation by the nonprofit newsroom ProPublica and the Times found dozens of instances in which staffing agencies skimped on background checks or ignored warnings from hospitals about sub-par nurses on their payrolls.
Surgeons have long listened to music while they work, saying it helps them relax and concentrate. But now Claudius Conrad, MD, an accomplished pianist and a senior surgical resident at Massachusetts General Hospital, is scientifically testing how music affects surgeons, their patients, and even relatives in the waiting room. The goal is to understand whether music can improve results of surgery, and whether it might be used as a medical treatment.
By a vote of 53 to 41, the Senate on Saturday rejected a Republican effort to block cutbacks in payments to home health agencies that provide nursing care and therapy to homebound Medicare beneficiaries. Republicans voted against the cuts, saying they would hurt some of the nation's most vulnerable citizens. Most Democrats supported the cutbacks, saying they would eliminate waste and inefficiency in home care, the New York Times reports. The Democrats' healthcare bill would reduce projected Medicare spending on home care by $43 billion, or 13%, over the next 10 years. The savings would help offset the cost of subsidizing coverage for the uninsured.
Senate Democrats are dismissing as "deception and distortion" a new health insurance industry study that alleges that the cost of premiums in the individual market would increase by 54% if healthcare reform passes.
"As Senate Democrats move closer to fixing our broken health system, the insurance industry continues their ‘say anything' strategy to deceive the public," said Jim Manley, spokesman for Senate Majority Leader Harry Reid of Nevada.
"So far, all we've gotten from the defenders of our broken health system is a series of misleading reports, scare tactics and an obstruction manual. They still have no plan to fix our broken system, no plan to curb the abuses within the insurance industry, and no plan to combat skyrocketing healthcare costs," Manley said in a media release. "These insurers and their defenders are scrambling to stand in the way of progress. But their campaign of deception and distortion will not derail our efforts because Americans' strong desire for reform grows with each passing day."
Manley was responding to a new actuarial analysis commissioned by the Blue Cross and Blue Shield Association, which stated that average annual medical claims in the new individual market will be 54% higher than they are today five years after implementation of the Patient Protection and Affordable Care Act.
The increase would translate into premiums for people purchasing new policies of $4,561 for single coverage and $9,669 for family coverage in today's dollars—representing premium increases of $1,576 and $3,341, respectively.
The study, conducted by Oliver Wyman, Inc., attributes the increases in costs for individuals to the inclusion of new guarantee issue rules without stronger coverage mandates.
"This means that many people are likely to wait to purchase coverage until they need it, raising premiums for everyone. Without a stronger coverage mechanism, and other changes to improve affordability, coverage levels are unlikely to reach more than 91% of the population," according to the report.
"Healthcare reform cannot be considered successful if it makes coverage more expensive," said Scott P. Serota, BCBSA president/CEO. "This analysis illustrates that is exactly what will happen if new insurance market reforms in the individual market are not paired with effective mechanisms to ensure broad participation in the market, as well as with sensible discounts for young people."
The analysis also found that premiums for the youngest 30% of the population, who are needed to help pay into a health insurance system that accepts more Americans, will increase by 35% as a direct result of the 3:1 age band included in PPACA.
"Significantly restricting age discounts coupled with a weak mandate will cause young people—who are critical to providing cross subsidies—to forgo coverage resulting in higher premiums for everyone," said Kurt Giesa, director, Oliver Wyman, Inc.
Individuals also would see premium increases as a result of new minimum benefit requirements, according to the analysis. The proposed benefit design requirements, including covered services and 60% minimal actuarial value, would lead to an average total premium increase of 14% in the individual market.
The Oliver Wyman analysis also found that costs would increase in the small group market as a result of the reforms included in the PPACA. Small employers purchasing new policies in the reformed market would experience premiums up to 20% higher in year five of reform, not including the impact of medical inflation. The analysis concluded that these premium increases would lead to fewer small employers offering coverage, with as many as 2.9 million fewer people insured through small-employer policies.
The new Oliver Wyman, Inc., analysis projects premium increases that are much higher than what the Congressional Budget Office recently estimated. While CBO's estimate recognizes the Senate proposal would increase premiums significantly in the individual market, it understates the impact in a few key areas that would affect the magnitude of expected premium changes:
Adverse selection would occur with weak coverage incentives as currently included in the Senate bill. CBO believes there will be "limited" adverse selection. However, experience shows if healthy individuals can wait to get coverage until they need it, many people will make that rational choice, according to the BCBSA report.
Newly insured people would be more costly than expected. Adding the previously uninsured would significantly increase premiums in the individual market. Contrary to CBO, Oliver Wyman's analysis of actual claims' costs in the individual market predicts that the uninsured would actually be 20% more expensive to insure than those in the individual market today, whose current population is much healthier. Had CBO adopted a similar assumption, their premium impact would have been higher.
The subsidies included in the bill would encourage participation, but are insufficient to drive effective coverage levels. Subsidies would lead a large percentage of those with incomes below 200% of the federal poverty level to purchase insurance. But subsidies would decline at higher income levels, and more than 18 million people, including both currently uninsured individuals and current members of the individual market, would be ineligible for subsidies. As a result, participation rates would be much lower for those above 200% FPL without meaningful incentives. In the first year of reform, 25% of the exchange eligible population is projected to exceed the 8% "affordability" threshold and are exempt from the mandate. Premium increases over a 10-year period are projected to result in nearly half of the population qualifying for mandate exemption status.
National estimates do not capture the true impact at the state level. The impact would vary significantly by state because of regional differences in rating laws today. Oliver Wyman found that two-thirds of Americans live in states where the average premium impact would be much higher than a national average.
A Medicare rule that will eliminate specialist physicians' ability to bill higher amounts for patient consults as of Jan. 1 "has caused a combination of panic and confusion" and should be postponed for a year, the American Medical Association wrote in a lengthy letter.
"Without such a delay, we anticipate payment denials, re-submissions and appeals that could create claims backlogs, cash flow problems and increased costs that could lead some physician to avoid Medicare patients," wrote Michael D. Maves, MD, AMA executive vice president, in a Nov. 25 letter to Jon Blum, director of the Center for Medicare Management of the Centers for Medicare and Medicaid Services.
The impact will be even worse "if Congress has not acted to prevent a scheduled 21.2% cut in the conversion factor that is scheduled to take effect on Jan. 1," he wrote.
Maves wrote that without a delay to educate doctors and consider the implications of the change, "two potential unintended consequences" will occur.
"First consulting physicians may stop accepting Medicare patients referred for consults. Second, more and more consultants may stop interpreting the findings in the medical record in a report back to the referring physician.
"Each scenario presents significant care coordination concerns and while CMS says it will be on the lookout for any unintended impact the new policy could have on care coordination, some real damage to individual patients could occur while CMS is still in monitoring mode."
Maves told Blum that "physicians will experience claims denials, audits and repayment demands, and conflicts with secondary payers simply for following the rules that CMS has laid out. Increased frustration and costs for physicians, payers and patients seem sure to follow."
Under current CMS rules, the CPT code for consultation calls for reimbursement that is between $20 and $50 higher than for a comparable office visit.
CMS officials has not responded to requests for comment.
Mapes met with CMS officials Nov. 24 about the elimination of CPT codes 99241-99244 for office or other outpatient consults and 99251-99255 for outpatient consultations. "Rather, CMS has instructed physicians to bill using the new or established patient codes instead."
Physicians who are concerned about the change say the elimination of these codes will necessitate substitution of evaluation and management codes, which pay significantly less.
"Unless the January deadline is moved back significantly, we do not see how Medicare will have sufficient time to educate physicians about the new modifier or to develop and widely distribute guidance —including a crosswalk —on how to use the visit codes. Time is also needed to educate secondary payers and provide them with enough time to handle impacted crossover claims."
Maves wrote that CMS rejected the AMA's CPT code panel's new language that would have clarified how consultation codes should be applied. "CMS apparently is rejecting this effort because there was not ‘universal agreement' among physicians on what the appropriate policy should be.
"Yet CMS' substitute policy has far less acceptance among physicians and has not been subjected to the cross-specialty scrutiny that could have identified and avoided some of the confusion and concerns the new policy has engendered among physicians."
The AMA's House of Delegates in November called for a repealing the new policy altogether.
I spoke with Paul Keckley director of Deloitte's Center for Health Solutions, on the latest developments on retail clinics. The business model has gone through its adolescent stage, he says, but it's here to stay. Hospitals should get in on this game, because consumers want it, it's a disruptive innovation, and it can drive business to their primary care physicians and ultimately, the hospital. Think EMR.
Is it possible that I just cannot do the math? Perhaps I just do not have the right perspective to understand the projected economics and concepts put forth in the variety of House and Senate bills flying fast and furious from our nation's brightest on Capitol Hill?
The premise seems to be that everyone can keep his favorite insurance coverage, keep his doctor, reduce her insurance premium, cover 30 to 40 million more people, keep Medicare the wonderful program it is, expand Medicaid to as much as 20% of the population, and, to add sugar to the deal, cut the federal deficit by $130 million.
Let me have some of that Kool-Aid. I can imagine how it's going to happen. They'll squeeze the evil capitalist insurance, pharmaceutical, and hospital industries, and create untold numbers of new government agencies to oversee and implement such efforts. Fortunately, we have seen how effective the government has been at running healthcare.
Medicare and Medicaid fraud has been rampant at about $120 million per year. The revenues to keep Medicare going are expected to be inadequate in just a few years, even without considering the 8,000 new baby-boomer beneficiaries per day who will be coming into the system. Meanwhile, Medicaid has already put a number of states into bankruptcy. I am not inspired.
If we have to legislate coverage, payment, and benefits, the political currencies will distort value and undermine success. When none of the bills include meaningful tort reform, changes that might recapture some of the $60 to $200 billion in estimated costs and better serve the public, something is wrong. The current system promotes cover-up, not safety or quality. It is a paradox that a reform effort to make healthcare an entitlement could be so short-sighted and self-righteous.
I thought Congress got solid negative feedback on the public option and several other elements in this legislation through town hall meetings and polls. However, they must have decided that we spent our gas and won't get in the way as they turn healthcare into another government-bungled bureaucracy.
With the persistence and insight of a testosterone-driven high-schooler with one thing on his mind, they keep coming back with a partisan approach saying "trust us; it's the right thing to do." What you can expect next is "I'm sorry" when they leave us with a single-payer healthcare system that will take decades to correct and which will sap our retirement funds.
There is no hope for an adequate revenue base in a society that has lost its ability to create jobs. The younger generation is looking at tax rates of 50% to 60%, with no guarantee of quality or access when they come of age.
I would much prefer seeing a two-tiered system that is defined in such a way that might preserve some of the attributes of our current system and inspire excellence and service. I would prefer to see the government subsidize physician and ancillary medical professional education that is paid back through work in these community health centers.
Issues with specialist and procedural referrals are solved by affiliation with a university medical center where faculty and residents would provide specialist and surgical care. This may be in urban areas near a medical campus or through telemedical technology which is poised and ready for prime time.
There would be a defined means-based cost sharing for individuals and families who qualify for these programs and initially they would be designed for those who do not qualify for Medicaid or CHIP, but would evolve as capacity allowed. These clinics would not be available to individuals with commercial insurance or outside of an income threshold.
This would allow for the commercial healthcare marketplace to improve on cost as the unreimbursed care moves into the community health clinic paradigm. It would also minimize the cost of education and training so physicians could pursue a career based upon interest more than profit and promote competitive improvements in care and service for the public. I know many might consider this idea a bit far reaching, but I would like to see the private sector supported, not stifled.
We are at a monumental moment in the self-focused eyes of our politicians. We need to move carefully, without partisan pressure, but with common sense. Healthcare is one-sixth of our economy and is an important employment base and focus of innovation for our national productivity. We do not need ultimatums demanding comprehensive health reform that must be done before Christmas. We need to find solutions that do not break our spirit—or our pocketbook.
Russell Libby, MD, is founder of the Virginia Pediatric Group in Fairfax and Herndon, VA. He may be reached at rlibby@vapg.com .For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
I've been hearing that the current rate of inflation for healthcare costs is unsustainable for about as long as I've been covering the industry—about 10 years.
I'm sure those of you who have been around longer than that have heard the same refrain for three and four times that long. In fact, it's been said so much, and yet, we continue to spend more and more of our gross domestic product on healthcare each year, far outpacing the inflation rate. It's kind of gotten like the boy who cried "wolf." No one pays attention anymore because it hasn't happened yet.
So what's different this time? Well, many hospital C-suite executives are starting to believe, and their actions say much more than any words from Washington ever could. Take Frank Perez, for example. He's CEO of Kettering Health Network in Dayton, Ohio. Perez and his team have been experimenting with ways to prepare for lower reimbursements for years.
Kettering was one of the baseline hospitals in the QUEST: High Performing Hospitals program that was developed out of Premier's CMS hospital quality demonstration project. Kettering's metrics measured in the top 10 of the program, which is aimed at developing the next generation of quality, safety, and cost metrics to improve healthcare nationwide. But his efforts didn't stop there.
During recent conversations with CEOs, I've learned that Perez and others are onto something in preparing for reimbursement that's nowhere near as generous as it has been in the past. Even if legislators are crying "wolf" yet again, long term, we have a major problem. In light of that, it seems logical that hospitals and health systems might do well to emulate these broad strategies.
1. Cut supply chain costs
This can be elementary or extremely complex. But the bottom line is that hospitals are spending outrageous amounts of money unnecessarily because they haven't worked with their physicians to standardize supplies. For many physicians, there are good reasons for having 10 varieties of a similar implant available for their use in the OR, for example, but certainly, there are at least equally good reasons to standardize for quality's sake, if not for the volume discounts hospitals can receive. Of course, physicians have to come together as a group to decide on these standards, but it's low-hanging fruit. Further, many savings can be generated from just-in-time inventory. Other industries have made great strides in electronic tracking of inventory, but hospitals haven't always followed.
2. Employ as many physicians as you can
It's a controversial subject, but physician employment seems a road many regulators and lawmakers want hospitals to pursue. This ensures unity of mission and purpose and largely eliminates many of the perverse incentives in healthcare that lead to waste and overutilization. At least that's what the feds say, and they are controlling the purse strings. Problem is, as CEO, you can get skewered if you try to encourage this too early. Eventually, many physicians will approach the hospital about partnering because their income levels have been reduced through cuts in their ancillary revenue streams. This is your time to strike. These days, it's smart not to do any joint ventures without at least exploring the possibility of employment.
3. Make do on Medicare reimbursement rates
Like many other forward-thinking hospital and health system administrators, Perez is operating under the assumption that his hospital needs to figure out a way to make do on Medicare reimbursement levels. He's not waiting on the legislation, figuring adapting to that new world might be too late.
"We know two things. We'll have higher transparency and lower reimbursement," he says. To work diligently on cutting costs, he incentivizes his managers with an internal pay-for-performance model based on keeping Kettering's costs at or below Medicare payments, "because one day, that may be all there is."
"When we put that in six years ago, I had some unhappy executives," he says. "They thought it was draconian, that I was mean and didn't like them, but the fact is that it also applies to me, so they can't say I was doing unto others what was not done to me. Now they are thankful they have been on this journey for over five years now. We can't cost shift like we used to."
These strategies are not cure-alls. But following these examples can help ensure your hospital isn't the one that ignores the "wolf" cry when it's finally the real thing.
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Facilities that are looking for a way to achieve a closer bond between hospital-based practitioners and their peers who work at satellite clinics should work with medical staff leaders to extend medical staff membership and hospital privileges to clinic practitioners.
Although medical staff membership is separate from clinical privileges, linking the two together can result in a medical staff with greater dedication to the organization. Just granting privileges alone will get the practitioners in the door, but what happens after that?
"I don't like the idea of providing access to your hospital without requiring [practitioners] also take on responsibilities that go along with medical staff membership," says Kathy Matzka, CPMSM, CPCS, a medical staff consultant from Lebanon, IL. "I don't think we should let them off the hook and give them a free pass. They need to be integrated into hospital organization."
Therefore, the benefits of hospital privileges, such as increased revenue from seeing more patients, should come with the responsibilities of medical staff membership, such as meeting attendance, according to Matzka.
Extending medical staff membership to practitioners who primarily work at satellite clinic locations is one way to ensure that those practitioners work as a unit with their hospital-based peers. But it's not the only way.
Here are three other tips hospitals can use to build camaraderie between the two groups. Remember that building relationships today can pave the way for smooth working conditions in the future.
Make medical staff meeting attendance mandatory, at least for some meetings. This guarantees that practitioners from multiple locations will gather in a central place to discuss issues that will affect all of them.
Hold social events or departmental meetings at clinic locations. Some clinics may not have appropriate meeting space, but if they do, explore this option. It will help convince satellite practitioners, who typically travel to the hospital for meetings, to attend, and it will give hospital-based practitioners a clearer picture of the off-site facilities.
Include news updates from the clinic in monthly hospital newsletters. Additionally, if the newsletter features a practitioner of the month or highlights the cutting-edge work of a particular team, include a photo along with the article. This will help the hospital-based practitioners get to know the satellite practitioners better.
Emily Berry is an associate editor for Briefings on Credentialing and Credentialing Resource Center Connection, and manages CredentialingResourceCenter.com. You can reach her at eberry@hcpro.com.
