"Strict MU requirements and deadlines [do not] provide sufficient time to focus on achieving interoperability" says a letter co-signed by eight provider organizations and large health systems.
Systemic snags and glitches around the interoperability of electronic health records are frustrating providers and doing little if anything to improve patient care or reduce costs, a group of provider organizations and large health systems says.
Sylvia M. Burwell
In a letter this week to Health and Human Services Secretary Sylvia M. Burwell, several provider groups and professional associations, including the American Medical Association, reaffirmed their support for meaningful use of EHR. However, the groups complained that stubborn proprietary barriers, the complexity of the requirements, and an accelerated timetable put forward by HHS have made it difficult to realize interoperability.
"Currently, health information stored in most EHRs/EMRs and other HIT systems and devices do not facilitate data exchange but 'lock-in' important patient data and other information that is needed to improve care," the letter says.
Citing data from the Office of the National Coordinator for HIT, the letter notes that only 14% of physicians can electronically transmit health information outside of their organization. The main barriers to data exchange continue to be "strict MU requirements and deadlines that do not provide sufficient time to focus on achieving interoperability."
"This dynamic is also in part due to the strict EHR certification requirements that have forced all the stakeholders involved to focus on meeting MU measures as opposed to developing more innovative technological solutions that will enhance patient care and safety while growing the marketplace," the letter says.
Paul Merrywell, vice president of information systems and CIO at Mountain States Health Alliance, which cosigned the letter to Burwell, says the Johnson City, TN-based health system is fairly well along in the meaningful use continuum but that the pace of implementation is "numbing" and the process still requires too many "manual processes and hand-holding."
"It is not a seamless process. It is not clicking-a-button easy because of the lack of interoperability between sending and receiving systems," he told HealthLeaders Media.
"For example, we have a certified product at Mountain States and a certified product at some other health system. So you would think we would be able to move a standard document from one organization to another programmatically. Well, eventually you can, but even with certified products there are incompatibilities between them due to a lack of interoperability."
In the letter, the eight co-signers recommend a handful of changes that they say could improve the meaningful use process, including:
Streamline and focus meaningful use certification requirements on interoperability, quality measure reporting, and privacy/security.
Remove certification mandates and instead allow for a flexible and scalable standard based on open system architectural features such as application program interfaces. This will allow data to move more freely across the healthcare system, reducing data lock-in and promoting more usable systems.
Foster stakeholder collaboration to promote new HIT that is focused on clinical care needs.
Remove restrictive MU policies that stifle HIT innovation.
Allow vendors and providers adequate time to develop, implement, and use newly deployed technology and systems before continuing on with subsequent stages of the MU program. Testing and achievement of specific performance benchmarks should occur before providers are held accountable for any new MU requirements.
The American Academy of Family Physicians was another of the cosigners in the letter to Burwell.
AAFP President Reid B. Blackwelder, MD, a Kingsport, TN-based family practitioner, says the EHR interoperability processes around his practice are almost laughably complex and inefficient.
"Let's just say I saw a patient today in my office and I decided this patient was sick enough to be admitted to the hospital, which is literally on the hill above my office," Blackwelder told HealthLeaders Media. "Well, the hospital has a different EHR. Ours don't communicate. I have to print out my electronic record, which has to be hand carried over and either scanned in or someone takes the time to enter that information into their EHR."
"Whatever happens in the hospital I can access because I have the hospital EHR access code because we are managing our patient in the hospital. But I can't send that information to my office except through paper and scanning, and when you scan a document it now becomes a miscellaneous item that you have to file. It's hard to track. It's hard to do research on the data."
"And when I send them home, I have to do the same thing with the discharge note from the hospital," Blackwelder says. "What's even more frustrating is that the electronic prescriptions from the hospital are going to be from a different system than the one in the office, so I have to reconcile the medication list by hand."
"That is just a practical example in one place but that is what I am hearing from our members," Blackwelder says. "What we have now are siloed electronic records. None of them talk to one another. And even when there is interoperability, it is usually very expensive and the costs falls on the physicians."
For the second time in just over a year, federal watchdogs are calling for a review of critical access criteria for hundreds of small rural hospitals across the nation. CAH proponents cannot wish the issue away.
For the second time in just over a year, federal watchdogs are calling for a review of critical access criteria for hundreds of small rural hospitals across the nation.
In August 2013, a report from the Office of the Inspector General for the Department of Health and Human Services recommended that Congress allow the Centers for Medicare & Medicaid Services to strip critical access designation from the nearly 1,000 hospitals with "permanent exemption" status under a state "necessary provider" designation.
The report triggered alarm bells from rural healthcare advocates. Alan Morgan, CEO of the National Rural Health Association, said at the time that "the practical effect is that it would kill rural health. I know that is a strong statement, but OIG viewed this with blinders on, not looking at how healthcare is delivered in rural America."
After the hue and cry from rural providers quieted, we didn't heard much more about that OIG report. This month, however, OIG quietly refloated the idea in a related report detailing the higher costs that Medicare beneficiaries pay for outpatient services at critical access hospitals, when compared with the same services at acute care hospitals.
OIG said CMS could mitigate the "potential increase in Medicare expenditures by ensuring that only those CAHs that meet all participation requirements continue to receive cost-based reimbursements."
In other words, only critical access hospitals that meet location requirements set out in the original federal legislation that created the designation could continue to receive cost-based reimbursements.
Unsurprisingly, rural providers still haven't warmed to the idea.
MaryEllen Pratt
CEO of St. James Parish Hospital
MaryEllen Pratt is CEO of St. James Parish Hospital, a 25-bed critical access hospital in Lutcher, LA, created under the necessary provider designation that serves 21,000 people in rural southeastern Louisiana.
For Pratt, a 35-mile yardstick recommended by OIG is no way to measure critical access status. "From where I am in South Louisiana, it seems pretty arbitrary to use a distance as a determinant of where access to care is necessary," says Pratt, who is also the chair-elect for the Governing Council of the Small or Rural Hospitals section of the American Hospital Association.
"If you've been to Louisiana, you know we have large areas of swampland making it very difficult to traverse. It doesn't matter that there might be a hospital within 15-20 miles through a swamp. If you don't have a boat to get through it you can't access it," she says.
"Some barriers are just related to poverty and having a vehicle to get from one place to another. Thirty-five miles is a long way to go when you don't have transportation."
Pratt also notes that CMS doesn't make distinctions when talking about nearby hospitals.
Priya Bathija
Senior Associate Director, Policy
at the AHA
"When they say 35 miles from another hospital, they're including anything that is a hospital, which could be a psychiatric-only facility or a rehab hospital. If you are having a heart attack and you need to go to the nearest hospital, I'm not thinking a psych hospital is going to help you out."
Pratt says the federal government should trusts that states knew what they were doing when they gave certain hospitals critical access status.
"The states were prudent with the way they designed things individually for each state. They did what they thought made sense to assure that their residents and Medicare beneficiaries had access to care," she says.
Priya Bathija, AHA's senior associate director, policy, says the AHA wants the federal government to address the higher copays for Medicare beneficiaries that were identified in the OIG report, but not in a way that would harm the critical access hospitals providing the care. Limiting the higher reimbursements only to hospitals that meet the mileage requirement is "simply an attempt to cut payments to hospitals providing essential health care services to seniors in rural communities."
"We are definitely alarmed by the fact that they've gone back to the same recommendation they made in August 2013," Bathija says. "We are doing our best to educate not only policymakers but Congressional staff about the benefits that critical access hospitals are providing for communities and the continued need for all the CAHs that have been designated through the program, either through the mileage requirement or because they were granted necessary provider status prior to 2006."
Here's my take on all of this.
Don't fault OIG for recommending a review of critical access status. It's their job as the watchdogs of taxpayer money in a vast and costly federal bureaucracy.
At some point CMS will attempt some sort of review of CAHs. Before they do, they need a transparent and exhaustive review of the criteria they will use to determine which hospitals get to keep their critical access status, giving providers ample time for input, review, and feedback. A 35-mile yardstick should not by itself determine whether some hospitals can continue to serve their communities or must close.
Any review of critical access criteria should wait until the Medicaid expansion takes hold in more states. Resistance to the expansion, which was always based on politics and spite, is rapidly crumbling as the benefits are demonstrated by the states that were smart enough to take the money.
On the provider side, even the staunchest advocate for critical access hospitals would not claim that every hospital under that status should be immune from periodic review. If I were playing with house money, I'd bet that more than a few hospitals with questionable criteria jumped on the critical access gravy train when they had a chance. I don't blame them. There's money in that status.
The bottom line is that this issue will not go away. If you're running a critical access hospital, you should expect to defend your status. Are you ready?
Research has shown that consumers "do think there is a difference," between for-profit and not-for-profit health plans, says the head of an industry group. But in the final rule on health insurance exchanges, CMS has declined to require that tax-status be disclosed.
Nonprofit health insurance plans continue to dominate customer satisfaction and quality lists, and they want consumers to know about it.
Bruce McPherson, president and CEO of the Alliance for Advancing Nonprofit Health Care, says federal and state health insurance exchanges should do more to make the tax status of health plans readily available to consumers.
"The research has shown that consumers do think there is a difference and it is important," McPherson says. "Right now both in the federal exchange and the state exchanges under the federal rules for every plan that is offered they have to provide consumers with a summary of benefits and coverage form. All of the key information is there for the consumer in a user-friendly format. The one item that we had urged (the Centers for Medicare & Medicaid Services) to include would indicate if it's a non-profit or a for-profit health plan."
In the end, CMS declined to include that tax-status in the final rule.
"They provided no explanation. They didn't comment on our request. I could not get a straight answer out of them," McPherson says. "I am going to try to get all of the nonprofit health plans together, as many as I can, to make a big push in Washington to get this changed.
McPherson says a Zogby telephone survey from 2010 found that two-thirds of respondents didn't know if their health coverage was provided by a for-profit or a nonprofit plan, even though 75% of the respondents said they felt the distinction was important.
The push for greater transparency comes as for the tenth straight year nonprofit plans dominate the National Committee for Quality Assurance annual rankings of health plans. Of the more than 1,400 plans ranked by NCQA, McPherson noted that:
100% of the Top 20 ranked private plans are nonprofit
95% of the Top 20 ranked Medicare plans are nonprofit
70% of the Top 20 Medicaid plans are nonprofit
In addition, McPherson says nonprofit plans have for the past eight years dominated the J.D. Power and Associates annual surveys for consumer satisfaction in rankings that combine for-profit and nonprofit plans.
"I guess it's just a part of sticking to the mission, which is all about quality and customer service and cost and access," McPherson says. "It comes down to trust more than anything. This may be true of other nonprofit healthcare providers as well; trusting that folks are going to be more concerned with doing the right thing than having profits as their primary goal."
"Making the information more accessible to the public means that more consumers could take advantage of that information and more of them would gravitate to the non-profit plans rather than the for-profits. And why not, since all this data shows that quality and customer satisfaction is typically better."
Idaho wants the U.S. Supreme Court to rule on whether or not private parties have the right to sue the state for noncompliance of Medicaid laws when Congress has not specifically provided that right.
The U.S. Supreme Court agreed this week to hear a convoluted case that pits healthcare providers against the state of Idaho in a battle over Medicaid reimbursements.
In a nutshell, the key issue before the court in Armstrong vs. Exceptional Child Care Center, Inc., is whether or not the Supremacy Clause in the U.S. Constitution grants providers the "private right" to sue the state to increase its Medicaid reimbursement rates.
Matt Salo
Executive Director,
National Association of Medicaid Directors
A federal district court in Idaho ruled in favor of the providers in 2012, and the 9th Circuit Court of Appeals upheld that ruling earlier this year. The 9th Circuit ruling appears to clash with a ruling by the 10th Circuit Court of Appeals in Douglas v. Independent Living Center of Southern California.
The Supreme Court, however, did not formally address the Supremacy Clause question when it heard Douglas in 2012. Now, Idaho wants the high court to rule on whether or not private parties have the right to sue the state for noncompliance of Medicaid laws when Congress has not specifically provided that right.
The high court is expected to hear oral arguments for Armstrong in early 2015.
The case hasn't gotten much publicity beyond healthcare circles, but it has generated a lot of anxiety and 29 states have joined with Idaho in filing amicus briefs with the high court. Matt Salo, executive director of the National Association of Medicaid Directors, says there are concerns in state capitols across the country that a Supreme Court ruling for providers would open the litigation floodgates.
'Only One Sensible Result'
"This would slow down the machinery of the program as every provider who thinks they want to get paid more is going to start bring suits forward," he says. "Medicaid agencies and directors at the state and federal level have a lot of real work that needs to get done. This will siphon a lot of energy and bandwidth. If the plaintiffs win, it's clear the end result will be [that] states will have to spend more money and not get anything for it in return."
The divergent appeals court rulings on the issue create "a ripe time for the Supreme Court to look at it and from our perspective there is only one sensible result, which is to say 'no.' States and the federal government are partners in trying to administer these programs that take into consideration cost effectiveness, access and efficiency for beneficiaries, providers and taxpayers' dollars," Salo says.
Idaho claims it should be the federal government, not private parties, that determine if the state's Medicaid program is in compliance. Idaho contends that the providers' lawsuit is not necessary because other remedies are available and that the Centers for Medicare & Medicaid Services has "a powerful enforcement mechanism" to keep states in line.
"CMS may initiate a compliance action and withhold federal funds," Idaho said in its complaint. "If, for example, a state's Medicaid expenditures are inconsistent with its state plan, CMS may disallow the expenditure and force the state to repay federal funds."
James M. Piotrowski, a Boise-based attorney for the providers, says his clients simply want the state of Idaho to pay them a higher reimbursement that they'd already agreed to pay. The suit was necessary, he says, because the state wasn't going to act on its own and "CMS doesn't have a method for providers to appeal such things."
Recession, Then Red Ink
In 2005, he says, the state devised a new funding formula that increased from $268 a day to $496 a day the residential care reimbursement for about 2,000 developmentally disabled adults. CMS approved the new formula. Then, the recession hit, red ink flowed, and the state legislature never found the extra $12 million a year needed to fund the new formula.
"So, the state simply continued to pay the old rate which was calculated by a now outdated method," Piotrowski says. "Of course, my clients asked the department to use the new rate, but they weren't willing to do so, and the legislature apparently was not prepared to fund them or to pay it."
"This case presents a rather unique circumstance," he says. "It's unusual for a state to seek CMS approval for a method of operation that they don't actually intend to follow, but that is exactly what they did here."
Piotrowski rejects the idea that a ruling in favor of the providers would prompt a stampede to the court house by every provider with a Medicaid beef.
"First of all there are quite a number of other requirements we have to meet before we can file suit," he says. "We have to prove that they were injured by the allegedly federally pre-empted action here. So, we cannot just as taxpayers go complain that emergency room services are under-reimbursed because I am not an emergency room provider. There will always be limits on who can sue coming from multiple doctrines that are already embedded in the law."
"This is a case where CMS acted in favor of my clients. CMS approved this rate-setting methodology and the state chose not to pursue it. That presents a very unique situation that very few states would find themselves in. So, I don't think we are talking about opening the floodgates."
Salo remains unconvinced.
"For us it's cut-and-dried issue," he says. "We really just don't need to have every entity that is somehow involved in the Medicaid program to be granted this private right of action to be able to sue the state and the program every time something comes along that they don't like."
The board of Watertown Regional Medical Center reviewed 23 suitors before deciding to pursue negotiations for a joint operating agreement with LifePoint Hospitals.
LifePoint Hospitals Inc. is negotiating a joint operating agreement with Watertown (WI) Regional Medical Center that if finalized, will mark LifePoint's entry into the Badger State.
"Hopefully this is the first of many," says Leif Murphy, EVP/CFO of Brentwood, TN-based LifePoint. "Watertown is a wonderful partnership opportunity for us and we believe that together with Watertown we will seek other opportunities across Wisconsin."
Located 52 miles west of Milwaukee, non-profit WRMC is a 55-bed general medical and surgery hospital that has clinical affiliations with UW Health.
John Kosanovich, president and CEO of WRMC, says the hospital's board had been considering some sort of affiliation over the past two years, and reviewed 23 suitors over the summer before deciding upon LifePoint.
"There was a large amount of research and due diligence done," Kosanovich says. "The board was impressed with LifePoint's track record of investing in and growing community hospitals that look much like ours across the country and feeling like they were most understanding of the situation of hospitals and organizations and communities our size."
The two parties are expected to continue negotiations toward a letter of intent to be finalized in the next six weeks. Details on the ownership arrangement beyond a JOA have yet to be made public, although WRMC will switch from nonprofit to for-profit status.
After due diligence and regulatory approvals, the hospitals expect to finalize the JOA in early 2015.
LifePoint has said it will:
Invest more than $100 million in WRMC. The WRMC board will use the money from the deal to create a foundation focused on community health;
Enhance and expand services locally, including WRMC's Wellness Initiatives;
Ensure equal representation on the hospital's governing board, preserving a local voice in the operation and strategic direction of WRMC;
Retain all jobs for WRMC's employees;
Promote WRMC's mission to serve all who need care;
Continue the clinical tertiary care affiliation with UW Health;
LifePoint, which operates more than 60 hospitals in 21 states, was drawn to Wisconsin because of the market's growth potential. Murphy says the for-profit hospital chain hopes to attract new partners in Wisconsin by demonstrating the value of the Watertown deal.
"We won't be aggressive at all. We will be responsive," Murphy said. "We are very excited about Watertown, but if it is the only opportunity we have in the state, we would still be excited."
"We would like to build a network of hospitals there, but that will be a function of the decisions made at the board level of different hospitals in the market," he said.
"It has been our experience that the message gets out with our track record. As we bring resources to Watertown, as we bring capital to Watertown, and as other community and hospital leaders in the market see the progress and the investments that are made, that is typically what takes root and brings invitations to us to come in and talk about whether or not we can make a difference in other communities."
Kosanovich says the WRMC board opted for the JOA instead of an outright acquisition or merger to maintain some level of local control.
"We are still early in this. We haven't signed a letter of intent. A lot of details need to be worked out," he says, "but the format in that joint venture structure and the way it is laid out made our board feel very comfortable that we would be able obtain the benefits and the resources that are available through LifePoint but still have active local involvement in the organization."
Murphy says LifePoint's partner Duke University Health System won't play a formal role in the Watertown JOA, but that the North Carolina health system's presence will be felt.
"Through our national quality affiliation Duke will have boots on the ground in Watertown," Murphy says. "From a program affiliation perspective, we've felt that there were strong partnerships in place with UW and we didn't want to interfere with those relationships by introducing another partner. But Duke will be another great resource for folks on the ground in quality, patient safety, and programmatic evaluation, and we will work to continue to develop those tertiary relationships with UW."
The general focus of the Duke-LifePoint brand is largely regional in North and South Carolina and Southern Virginia, Murphy says. It’s also an option for hospital acquisitions outside of that region that require clinical expertise in tertiary care, such as Marquette (MI) General Hospital, and Conemaugh Health System, in Johnstown, PA. "With secondary hospitals, especially when there is a more natural geographic partner, we will look to that more natural geographic partner for the clinical affiliations," Murphy says.
A scorecard released by the American Medical Student Association finds that most of the hospitals reviewed had policies in place for internal disclosure of potential conflicts of interest, but no policies for disclosure to the public.
The results were release this week as the federal government launched its Medicare Open Payments website, which contains data on payments by drug and device makers to physicians and teaching hospitals.
Of the 204 teaching hospitals examined, 35 received A's (17%), 111 received B's (54%), 31 received C's (15%), and 27 (13%) were graded "incomplete."
"As physicians-in-training, we have to be confident that the education we are receiving is free from conflict of interest," Britani Kessler, MD, AMSA's national president, said in prepared remarks. "That is why it is so important to AMSA to advocate on behalf of students to ensure that we retain the right to unbiased training."
The scorecard found that most of the hospitals studied had policies in place for internal disclosure of potential conflicts of interest, but no policies for disclosure to the public. Only 19 teaching hospitals met "model" criteria for disclosing potential conflicts of interest both internally and externally.
Heather Pierce, senior director, science policy and regulatory counsel, at the Association of American Medical Colleges, whose members include more than 140 teaching hospitals, declined to talk specifically about the report because she hadn't read it.
Pierce says that conflict-of-interest policies at teaching hospitals are different than those policies required of medical schools. "There may be less consistency in the written policies in terms of how things are phrased and addressed," she says.
"Generally though, at both medical schools and teaching hospitals, conflict of interest procedures and activities are pretty robust and have been developing to really address concerns that actual or perceived conflicts of interest could in some ways be harmful to patients or research subjects or to data and are created to safeguard against those conflicts of interest."
The rating is part of AMSA's Just Medicine Campaign, formerly called the AMSA PharmFree Scorecard. AMSA said the scorecard can provide medical students searching for a residency program with "an easily digestible view of each institution's attitude toward industry influence."
AMSA said its scorecard brings a measure of public accountability for pharmaceutical and medical device manufacturers' influence on purchasing decisions and even on the therapies available to patients at teaching hospitals.
Pierce says conflict of interest policy "has been on the radar for over a decade" at most medical schools and teaching hospitals.
"There are a lot of activities and processes that go into thinking about this," she says. "Part of a robust conflict-of-interest policy is the piece that allows institutions to know about, review, analyze and if necessary manage various financial interests of physicians, researchers or the institution itself to ensure that data, and patients, and clinical care and education are free of problematic relationships."
"It's important to note that there are many reasons why individuals and institutions do engage with industry in productive ways that advance discovery and biomedical research that can lead to better health and healthcare. Those are the kinds of relationships that our institutions not only allow but encourage."
Physicians Foundation data shows that 44% of physicians surveyed said they would reduce the number of patients they see to alleviate the demands of the profession.
As the nation adjusts to Medicaid expansion, a graying demographic, and extended health insurance coverage for millions of Americans through the public exchanges, 81% of physicians say they're either overextended or at full capacity, The Physicians Foundation survey shows.
Joseph Valenti, MD
While 19% of the 20,088 physicians surveyed said they would take on more patients, 44% said they would reduce the number of patients they see, either by reducing their workload, working part-time, retiring, or transitioning to non-clinical jobs.
"The biggest thing that physicians are concerned about is their ability to spend time with their patients. Eighty percent of them will still say the most important thing is their relationship with the patients," says Joseph Valenti, MD, an OB/GYN practicing in Denton, TX, and a member of The Physician Foundation board.
"But many say that between entering data and calling for prescriptions permission and trying to avoid Medicare penalties, when is there time to see my patients? The thing we found most impressive about this survey, besides its actual breadth and depth, is that physicians want to spend time with their patients, but there are so many forces keeping them from doing that."
In 2014, the average age of the respondents was 50, versus an average age of 54 in 2012, the last time The Physician Foundation conducted such a survey. In 2014, 33% of the survey respondents were female, versus 26% in 2012.
Along with the changing workforce demographics, the survey verified the profound transitions underway in physician practice settings. In 2014, only 17% of physicians were in solo practice, down from 25% in 2012. In 2014, only 35% of physicians were independent practice owners, down from 49% in 2012 and 62% in 2008.
Fifty-three percent of respondents were employees of a hospital or medical group, up from 44% in 2012 and 38% in 2008. More than two-thirds of employed physicians (68%) said they were concerned about their clinical autonomy.
"Things are changing that rapidly," Valenti says. "We are seeing a lot more people wanting to go to an employed situation because they are so pessimistic about private practice. There is so much rapid consolidation in healthcare to control referrals and business that physicians are being swept up in that consolidation."
"Certainly they're paid better with better contracts in groups that are larger, whereas a small group such as mine doesn't have the latitude to negotiation contracts. And a lot are becoming more family-oriented. It creates a problem for physician shortages because replacing FTE who used to work 60–70 hours a week with two people who want to work 35–40 hours a week creates a physician shortage for us."
In 2014, 56% of physicians described their morale as somewhat to very negative. However, 44% said they were somewhat or very positive about the current state of the medical profession, compared to 32% in 2012.
A physician's pessimism or optimism about medicine seems to depend, in part, on generation and gender. Specifically, 54% of physicians ages 45 or younger are optimistic about the state of medicine, versus 30% of physicians ages 46 or older.
Among female physicians, 49% are slightly more optimistic about the current state of medicine than their male counterparts (42%.) Fifty-one percent of employed physicians are optimistic about the current state of the medical profession, compared to 33% of physicians who own their own practice.
Generation and job model appeared to help determine if a physician supports or dislikes the Affordable Care Act. Sixty-three percent of employed physicians ages 45 or younger were more inclined to give the ACA a favorable rating.
The survey also found that:
39% of physicians said that they will accelerate retirement plans due to changes in the healthcare system
26% of physicians now participate in an Accountable Care Organization, but only 13% believe ACOs will enhance quality and decrease costs
50% said implementation of ICD-10 will cause severe administrative problems in their practices
Physicians spend 20% of their time on non-clinical paperwork
On average, physicians said 49% of their patients are in Medicare or Medicaid
38% either do not see Medicaid patients or limit the number of Medicaid Patients they see
Physicians work an average of 53 hours per week and see approximately 20 patients per day
Healthcare executives like to talk about transparency, but what efforts are made to ensure that very sick patients understand that payment schemes involving out-of-network physicians and services could add tens of thousands of dollars to their out-of-pocket expenses?
The Kaiser Family Foundation published a study this year which found that one in three Americans has difficulty paying for medical debts. KFF data further shows that 70% of people with medical debt are insured, and that people with employer-sponsored coverage represent 54% of medical debt cases.
In other words, responsible working people who are trying to provide health insurance coverage for themselves and their families and to protect their assets still face a likelihood of incurring life-altering medical debt if they get sick.
One reason for this is because most healthcare consumers are not experienced or sophisticated enough to protect themselves when they come into contact with the complicated, labyrinthine payment schemes designed by physicians and hospitals to extract money.
Case in point: The New York Times and the Tampa Bay Times recently detailed the practices of "drive-by doctoring" and balance billing—schemes that have been around for a while, but which have found new enthusiasts among providers as reimbursements shrink. The cases highlighted in the two newspapers are galling and brazen and indefensible.
There are common themes that run like this: An insured patient has a medical emergency that requires her to go to the hospital, arriving at the emergency department in great pain and duress. Fortunately, the hospital is in her network.
Unfortunately, and probably unbeknownst to the patient, the emergency physician, the hospitalist, the anesthesiologist and the rehab bed are contract hires who don't accept her insurance plan.
Healthcare executives like to talk about transparency, but what efforts are made to ensure that a frightened and injured patient understands that these out-of-network physicians and services could add tens of thousands of dollars to her out-of-pocket expenses?
And frankly, even if the patient knew this, what could she do about it while strapped to a gurney with a tube sticking out of her throat? What alternatives does she have?
Is there any other industry where that sort of business practice is allowed, or even legal? Imagine, for example, buying a house and learning after the fact that an appraiser you never met was hired without your knowledge or permission for a service you didn't ask for, and then sent you a bill for $10,000, and threatened to dun your wages and ruin your credit if you didn't pay. By this measure the home loan industry is a paragon of virtue when compared to the billing shenanigans practiced by some hospitals and physicians.
"It does happen all the time and people do get caught by it," says Karen Pollitz, a senior researcher with the Kaiser Family Foundation. "I don't know why it's showing [up in the media] now like we just discovered it. This isn't a new problem. But it does surprise people when it happens to them and as we found in some of our case studies in our medical debt report, this can bankrupt people. In one extreme example, one family lost their house."
Pollitz recalls speaking to one woman who was told that her seriously ill husband would be moved to a rehab bed within the hospital that was managed by an out-of-network provider.
"The wife was told, but what was she going to do? He's got a PICC line. He is barely breathing. He can't be discharged," Pollitz says. "They said 'we can't really move him anywhere but to the next floor' so she said 'OK." What was she going to say? 'No. I'm going to shop around. Just leave him in the elevator while I look.'"
We shouldn't lay blame on any one group, because there's plenty of blame to go around. And the response from providers and payers is to point the finger at one another. Do physicians and administrators making solid six-figure incomes stop to consider how these questionable billing practices have the potential to bankrupt their patients, most of whom reside in far lower tax brackets?
The median household income in the United States this year was $53,800, which is 4.8% lower than it was at the start of the Great Recession in 2007. One of the biggest reasons for wage stagnation is the rising cost of health insurance.
Everyone in the healthcare industry must understand the potential for blowback when a sizeable number of patients come to believe they've been fleeced by people they thought they could trust. Using social media patients can organize quickly, compare notes, and identify perpetrators. Patients have compelling cases and legitimate complaints that resonate with the larger public.
It's probably naïve to think that payers and providers can resolve this amongst themselves. This will require government. The Tampa Bay Times notes that the Patient Protection and Affordable Care Act offers some protections against insurance companies charging patients more for out-of-network emergency care, but it does nothing to address drive-by doctoring and balance billing by hospitals and physicians. Mandatory annual caps of out-of-pocket expenses are only for network care.
There are hodge-podge laws in several states that mitigate the expenses. New York State is considering a bill (Section H, page 160) that provides protections against billing schemes leveled at emergency medicine patients. They need to make it law.
Someone has to stand up for the consumers who are stuck with the tab for a dysfunctional relationship between payers and providers.
Despite a projected surge in primary care visits as a result of coverage expansion, only one in six recent medical school graduates say they will pursue primary care as their field of residency, survey data from UnitedHealth shows.
Better access to primary care doctors is linked to reduced hospital admissions and emergency department visits, a report from UnitedHealth Group's Center for Health Reform & Moderation shows.
"What this report does try to highlight is that primary care is a cornerstone of an effective and high-performing healthcare system," says Lewis G. Sandy, MD, an internist and executive vice president, clinical advancement, at UnitedHealth Group.
"We see the demand for primary care is growing, particularly now in the post-Affordable Care Act environment. There could be more than 25 million more primary care visits annually as a result of coverage expansion and the growth in the senior population and increasing rates of chronic illness."
Despite this correlation between better healthcare and reduced cost, the numbers of primary care office visits declined from 2013–14, and only one in six recent medical school graduates (16%) said they would pursue primary care as their field of residency, the study found.
"There is evidence that the vast majority of entering medical students have an interest in primary care but at the other end of the pipeline those numbers drop significantly," Sandy says.
"One of the reasons is that medical students and physicians in training don't always see how it is they can have a satisfying professional life that lets them practice in the way they want to practice on behalf of their patients if they don't see models where they can see themselves in the primary care picture."
Sandy says the sense that primary care physicians are overwhelmed is not limited to medical students or residents, and demonstrates the need for more physician-led primary care teams.
"One of the things I hear regularly from primary care physicians is about the significant amount of work they are asked to take on. They say it is too much for one person," he says.
"We say 'you're right. That is why you need a multidisciplinary care team in place to support you and let everyone work at the top of their expertise, doing what they do best on behalf of the patient.' There are many other reasons, including issues around role modeling, payment, and lifestyle issues. Those things need addressing as well."
Unfortunately, primary care physicians also gravitate away from poorer areas with higher rates of uninsured, and rural areas, where their services are needed more acutely.
"There are real challenges, particularly in rural areas," Sandy says. "The good news is that there are practical solutions that can offer new access points in those locales. For example, the growth of retail clinics. These are new opportunities for people to get primary care services where they live. The use of technology like telemedicine allows the barriers of time and distance to be overcome and connect people to services. Everyone should have a primary care physician, but they may not need a face-to-face visit. So technology can help address those issues as well."
The UnitedHealth Group report offers these recommendations to improve care and stabilize costs:
Implement payment models that reward value. Government programs and private health plans should continue partneringwith physicians, hospitals and other providers to emphasize primary care in aneffort to improve quality and reduce costs.
Expand the roles of nurse practitioners and physician assistants. While laws governing scope of practice vary by state, there are opportunities to better utilize these skilled providers to boost capacity and improve access to primary care.
Create multi-disciplinary care teams. It would take 17 hours per day for a primary care physician to provide all recommended care to a panel of 2,000 patients – and many have larger panels than that. In addition to NPs and PAs, care teams should expand the role of medical assistants and health coaches.
Use electronic health records and other HIT to share information and coordinate care in real time. HIT alone will not achieve dramatic improvements in primary care delivery but it enables practices to use resources more efficiently andeffectively.
Sandy says payers can play a critical role in bringing about these recommendations by "continuing to support innovation in care delivery."
"To develop not only the care model, but also—and this is clearly in the wheelhouse of the payer—to start modernizing the payment model that emphasizes payment for value, payment for outcomes, and support for these new models. For example the patient-centered medical home, where we typically use a blended payment model combining fee for service and other elements to support that new model: That new model came from the primary care community itself," he says.
"If we work together, we can grow this and build a new payment approach. That is what the payer community can do and we believe strongly in doing that, which is why we wrote this report.
The American Medical Association says it supports the National Governors Association's recommendations, which "closely align with AMA's policy supporting healthcare teams that draw on telemedicine and the unique strengths of physicians and physician assistants."
The National Governors Association says states should review and consider easing scope-of-practice restrictions on physician assistants so they can help with growing patient workloads anticipated under healthcare reform and the Medicaid expansion.
"PAs are an important component of developing strategies to deliver healthcare more efficiently and effectively," Washington Gov. Jay Inslee (D) said in prepared remarks accompanying the release of The Role of Physician Assistants in Health Care Delivery.
"Finding ways to eliminate the regulatory barriers that exist for PAs is crucial to growing the profession," he said.
The report identifies barriers that prevent PAs from practicing at the top of their license, and offers suggestions for state policy leaders who are trying to maximize the efficiencies of their PA workforce.
For starters, the NGA report says states should review their existing laws and regulatory framework for PAs to ensure they aren't antiquated, unduly narrow, or overly burdensome on the profession, and that they're not restricting the future supply of PAs.
In addition, the report recommends that all states grant PAs legal standing to provide care under laws governing medical practice. The report also recommends that states create greater educational opportunities for PAs.
"Our state has an effective program, and one that educates returning veterans, typically medics, to become PAs to fill important primary care jobs," Inslee said. Physician associations have offered guarded and conditional support for PAs as members of a care team led by physicians.
"The American Medical Association commends the National Governors Association for its examination of the role of physician assistants in health care delivery," said Robert M. Wah, MD, president of the American Medical Association, in a media statement.
"The NGA's recommendations closely align with AMA's policy supporting healthcare teams that draw on telemedicine and the unique strengths of physicians and physician assistants to ensure access to coordinated, patient-centered quality care."
American Academy of Physician Assistants President John McGinnity, MS, PA-C, reached last week, says he is delighted by the report, and not surprised by its recommendations.
"We've been saying this for two or three years now, that folks are recognizing the role that PAs can play in healthcare. Now it is exciting to see everybody starting to believe in things we've been doing for many years," McGinnity says.
"For a long time I've been saying we are the best-trained most flexible profession to handle our nation's healthcare needs. When you look at the average PA who's been in practice for more than 10 years, they've changed specialties at least twice. That's a unique flexibility that PAs offer the healthcare team, the flexibility to go where marketplace needs are."
McGinnity says the number PAs has more than doubled each decade since the profession was created in 1967. "We have over 100,000 practicing PAs. We have 191 programs in the nation and we are graduating more than 6,000 PAs each year. I see barriers falling left and right," he says.
"The problem is that when these laws were written, PAs really weren't around. The states need to go back and update antiquated laws to say 'OK, how can we have all clinicians, no matter who they are, practicing as a team?' That is really the key. We've been doing team before team was cool. We wanted to partner with everyone in healthcare just to improve patient outcomes."
McGinnity argues that regulations for PAs should "equate" to regulations for physicians.
"They should treat PAs as they do physicians," he says. "We practice medicine. We're trained in the medical model and we need to remove those barriers to improve access for patients. This is truly about the patient."
While scope-of-practice skirmishes continue with physicians, McGinnity believes there is also a growing mutual respect in both camps and a sense that they need each other. "You've now got states where the medical society and the PA groups are saying 'Hey listen. Medicine is a team sport,'" he says.
"Do we all agree 100% of the time? No! Are we working together to try to come up with solutions? Absolutely!"
