The Medical Group Management Association told HHS this week that new HIPAA disclosure requirements for electronic medical records are burdensome, unnecessary, costly, and may discourage physicians from adopting the new technology.
The 2003 HIPAA Privacy Rule permits patients to request an accounting of disclosures of their protected health information. However, a new provision expands the type of information required in this accounting, and medical groups using EMR are now required to track all disclosures of patient information, including treatment, payment, and healthcare operation.
"MGMA asserts that this onerous new requirement on physician practices will be extremely difficult to achieve without an enormous outlay of resources," MGMA President and CEO William F. Jessee, MD, said in a 21-page letter to Georgina C. Verdugo, director of HHS's Office for Civil Rights. "These resources would be better utilized by physician practices to provide direct patient care. This mandate runs counter to the nation's efforts to improve patient care and reduce waste and inefficiency through administrative simplification and adoption of electronic health records."
An MGMA online survey of more than 360 practice administrators, representing more than 7,000 physicians, found most administrators had received very few accounting for disclosure requests from patients since 2003. The survey respondents expressed concerns about the cost, staff training, and computer upgrades required for compliance.
MGMA highlighted five critical concerns:
Administrative burden on physician practices;
Low volume of patient requests for accounting reports;
Burdensome and unnecessary accounting for treatment disclosures;
Burdensome and unnecessary accounting for payment and healthcare operations disclosures;
The rule's discouraging effect on physician adoption of EHRs.
While calling MGMA "a strong supporter of patient access to and protection of their health information," Jessee asked Verdugo for "significant modification to the requirements and request that OCR continue to closely monitor the industry to ascertain the impact of this regulation on physician practices."
Jessee's letter was in response to the "HIPAA Privacy Rule Accounting of Disclosures Under the Health Information Technology for Economic and Clinical Health Act; Request for Information," which was published in the May 3 Federal Register.
Health Savings Accounts began in January 2004. Since then, AHIP has conducted a periodic census of health plans participating in the HSA/high-deductible health plan market. "HSA plans continue to be an important coverage option for families and small businesses across the country," said Karen Ignagni, AHIP president and CEO, in a media release.
The census also found that:
Between January 2009 and January 2010, the fastest growing market for HSA/HDHP products was large-group coverage, which rose by 33%, followed by small-group coverage, which grew by 22%.
30% of individuals covered by an HSA plan were in the small group market, 50% of individuals covered by an HSA plan were in the large-group market, and the remaining 20% were in the individual market.
In the individual market, 2.1 million people are enrolled in HSA plans, while nearly 3 million people were enrolled in HSA/HDHP coverage in the small-group market and almost 5 million people were covered in the large-group market.
HSAs have grown steadily since first authorized in 2003. Approximately 1 million lives were covered under the plans when AHIP began surveying the market in 2005, and roughly 2 million have been added each year since.
Despite the steady growth, the makeup of the HSA/HDHP market has changed significantly since the plans were introduced. In 2005, 64% of the high-deductible plans were in the individual market, compared to only 20% in January 2010.
The group markets now account for the largest percentage of HSAs, with large groups accounting for 50% of the plans and small groups for 30%.
"What you've seen over last year is that a large percentage of growth has come from employers," says Robert Zirkelbach, spokesman for AHIP. "More employees in large and small companies are choosing to enroll in these plans. That can be a reflection of both more employers offering them and more employees showing interest."
Despite the growth, nearly 40% of people who are eligible to enroll in an HSA don't open one, according to a 2008 report from the Government Accountability Office. The report also found that HSA users tend to have much higher incomes—on average about $139,000, compared to $57,000 for other tax filers.
It is unclear if or how recently-passed healthcare reform legislation will change the patterns of consumer-directed health plan use. Although some legislators tried to include amendments that would kill or weaken HSAs, the plans made it through the reform process with only some minor changes to spending rules.
When health insurance becomes mandatory, more individuals and employers may look to HSAs to meet the new coverage requirements. In Massachusetts, where insurance is already required, HSAs/HDHPs represent 6.9% of of total private insurance plans, which is above the 4.8% average for the nation. However, Massachusetts doesn't have the highest percentage of HSA enrollees. States with the most include Vermont (13.8%), Minnesota (9.2%), Colorado (9.2%), Arkansas (8.2%), Indiana (8.1%), Ohio (8%), Louisiana and Nebraska (7.5%).
"I think it's too early to know what impact healthcare reform will have on these types of plans." Zirkelbach says. "A lot of the final requirements need to be refined through regulations that have yet to be developed, so it's hard to know what the impact will be. But clearly you've seen consistent growth in these plans and interest in them."
St. Joseph's Women's Hospital in Tampa will hold a groundbreaking ceremony on Wednesday for its $75 million expansion.
The 125,000 square feet, five-story building will house the St. Joseph's Children's Hospital's Level II and Level III-licensed Neonatal ICU, which includes 64 private rooms; and the Hinks and Elaine Shimberg Breast Center, a dedicated women's imaging center with diagnostic services including CT Scanner, Ultrasound, DEXA Scan and MRI, and 24 private patient rooms.
St. Joseph's Hospitals President/CEO Isaac Mallah and Tampa Mayor Pam Iorio will take part in the midmorning groundbreaking ceremonies, which will include tours of model rooms for the expansion.
The Florida Hospital Association and the American College of Surgeons today launched a joint Florida Surgical Care Initiative—a statewide program to improve patient safety and surgical care while reducing costly complications.
"Quality care is a core value for our hospitals and surgeons, but complications still occur," FHA President Bruce Rueben said in a media release. "By working together, we'll be able to significantly improve care, prevent complications, reduce costs and demonstrate to the nation that Florida is a leader in quality healthcare."
Regional variation in the quality and cost of care has been identified as a critical issue for the nation's healthcare system, and FHA hopes the initiative will allow its member hospitals to proactively tackle the issue.
Funded in part by a grant from Blue Cross and Blue Shield of Florida, FSCI will focus on:
Surgical site and urinary tract infections—two of the most common complications.
Colorectal surgery outcomes—an area with higher rates of complications.
Elderly surgery outcomes—because elderly patients are more likely to experience complications.
Proponents say ACS NSQIP reduces complications and deaths at participating hospitals and saves money by preventing complications, which can add $11,000 or more to the cost of care for each patient.
Clifford Ko, MD, director of ACS NSQIP, said FSCI is unlike other quality improvement programs because it is based on hard clinical data and patient follow-ups for 30 days after they leave the hospital.
"Before you can improve quality, you must first be able to accurately measure it," Ko said. "You wouldn't want your doctor to determine the next steps in your care by looking at your billing information. Nor should we be relying on that information alone to judge the quality of the care provided."
The FSCI measures—developed by ACS and CMS—are under review by the National Quality Forum and could become national quality measures by CMS. Florida hospitals are the first in the nation to participate in this outcomes-based program.
"If we achieved the quality improvements that we know are possible, we could free up resources that could, in turn, be used to expand access to healthcare in our country," said David Hoyt, MD, executive director of ACS. "Florida hospitals will lead the nation in showing that proven programs like the ACS NSQIP can significantly improve patient care while reducing costs, and provide an example for other states to follow."
Nine hospitals in seven states will pay the federal government more than $9.4 million to settle whistleblower allegations that they overcharged Medicare for spinal kyphoplasty procedures, the Justice Department announced.
The nine hospitals and the amount being paid by each are:
Ball Memorial Hospital, Muncie, IN ($1,995,431)
Bethesda Memorial Hospital, Boynton Beach, FL ($356,079)
Bloomington (IN) Hospital. ($1,443,848)
Genesys Regional Medical Center, Grand Blanc, MI ($931,742)
Huntsville (AL) Hospital, dba The Health Care Authority of the City of Huntsville ($1,992,756)
Palmetto Health, dba Palmetto Health Baptist Hospital, Columbia, SC ($1,861,083.14)
St. Elizabeth Medical Center, Utica, NY ($195,976)
St. Mary's of Michigan Hospital, Saginaw MI ($260,065.21)
United Hospital, St. Paul, MN ($428,656).
The Department of Justice said in a media release that the settlements resolve allegations that the hospitals overcharged Medicare between 2000 and 2008 when performing kyphoplasty, a minimally-invasive procedure used to treat certain spinal fractures that often are due to osteoporosis. The government contends that the hospitals performed the procedure on an in-patient basis in order to increase their Medicare billings.
"These hospitals put profits ahead of sound medical judgment," said Tony West, assistant attorney general for the Civil Division of the Department of Justice.
In May and September 2009, the DOJ reached settlements with nine other hospitals for alleged kyphoplasty-related Medicare fraud claims, and in May 2008 Medtronic Spine LLC, corporate successor to Kyphon Inc. Medtronic Spine paid $75 million to settle allegations that the company defrauded Medicare by counseling hospital providers to perform kyphoplasty procedures as an in-patient procedure, even though in many cases the minimally-invasive procedure should have been done on an out-patient basis.
All but two of the settling hospitals–St. Elizabeth Medical Center and United Hospital–were named as defendants in a lawsuit filed under the False Claims Act in 2008 in federal district court in Buffalo, NY, by whistleblowers Craig Patrick and Charles Bates. Patrick of Hudson, WI, is a former reimbursement manager for Kyphon, and Bates is a former regional sales manager for Kyphon in Birmingham, AL. They will split $1.5 million as their share of the settlement proceeds.
Universal Health Services, Inc. will acquire Psychiatric Solutions, Inc. in a deal that includes $2 billion to purchase PSI at $33.75 a share, and $1.1 billion to assume its debts, the two companies announced.
Franklin, TN-based PSI is the nation's largest standalone operator of owned or leased freestanding psychiatric inpatient facilities with 94 facilities in 32 states, Puerto Rico, and the U.S. Virgin Islands. UHS owns or operates 25 acute care hospitals and 102 behavioral healthcare facilities and schools in 32 states, Washington, DC, and Puerto Rico.
The 2009 combined revenue and EBITDA of UHS and PSI was more than $7 billion and approximately $1.1 billion, respectively. On a combined basis, in 2009 the company had approximately 6.2 million patient days in 221 heathcare facilities in 37 states and territories. With the acquisition, King of Prussia, PA-based UHS' revenue from the behavioral healthcare business will represent approximately 45% of combined 2009 revenue and approximately 54% of combined 2009 EBITDA, before UHS' corporate overhead costs.
"The combination with PSI will further strengthen our behavioral health division, which has already grown substantially through capacity expansion and strategic acquisitions," said Alan B. Miller, CEO/chairman of UHS. “Importantly, the combined company will have ample opportunities for further growth in both the acute care and behavioral healthcare sectors."
The acquisition is expected to generate approximately $35-45 million in annual cost synergies within three years, with the majority occurring in years one and two. Excluding one-time costs related to the acquisition, the transaction is expected to be significantly accretive to UHS' earnings per share. In 2009, PSI's revenue was $1.8 billion with EBITDA of approximately $330 million.
The transaction was unanimously approved by the board of directors of UHS. PSI's board, acting on the unanimous recommendation of a special committee, approved the agreement and recommended that PSI shareholders do so as well.
UHS expects to complete the transaction in the fourth quarter of 2010, subject to customary closing conditions.
Dartmouth College has received a $35 million anonymous gift to establish a multidisciplinary Center for Health Care Delivery Science, President Jim Yong Kim announced today.
"We know—and this has been documented by the Dartmouth Atlas of Health Care—that there are glaring variations in how medical resources are used in the U.S. More care and more expensive care do not guarantee high quality care," Kim said in a media release. "What we need is a new field that brings the best minds—from management, systems engineering, anthropology, sociology, the medical humanities, environmental science, economics, health services research, and medicine—to focus on how we deliver the best quality care, in the best way, to patients nationally and globally. Those people are here at Dartmouth."
The center will integrate experts from the Arts and Sciences, the Tuck School of Business, the Thayer School of Engineering, Dartmouth Medical School, The Dartmouth Institute for Health Policy and Clinical Practice, and Dartmouth-Hitchcock, an affiliated academic health system, which will provide the base for innovation and implementation in clinical practice.
The initiatives include a new master's program in Health Care Delivery Science, offered by The Dartmouth Institute and the Tuck School of Business.
Traditional healthcare management courses have been built around general "best business" practices from a wide range of professions. The Dartmouth curriculum will be unique in its singular focus on discovery and analysis of innovations and real-time implementation in healthcare. Executive education and distance learning will be incorporated into the new degree program, scheduled to enroll its first class in July 2011. Undergraduate offerings in this field will be developed as well, Kim said.
The Center for Health Care Delivery Science will focus on five areas, including:
Research:
An expanded research agenda at Dartmouth and with partners around the country, building on the work of The Dartmouth Institute for Health Policy and Clinical Practice, and focusing on healthcare delivery.
An international research network that will bring together innovation centers to develop, study and disseminate best practices.
A grant award program to encourage research in the field.
Education:
A new curriculum in the delivery of healthcare to be incorporated into medical education at Dartmouth.
A consortium of medical schools committed to integrating Health Care Delivery Science into their academic programs.
Undergraduate courses, cross-disciplinary offerings through the Tuck School of Business, Thayer School of Engineering, Dartmouth Medical School and the Arts and Sciences, and new distance and executive learning opportunities.
A journal of healthcare delivery science, to advance dissemination, research, and learning.
Collaboration:
Partnerships across a diversity of healthcare systems in the U.S. and beyond, to define best practices and integrate them into clinical practice.
Joint efforts with academic institutions nationally and internationally to expand the new field of Health Care Delivery Science.
Implementation:
Development and deployment of measures beyond clinical outcomes, to evaluate the quality and value of care, with patient-reported data and longitudinal tracking incorporated into enhanced Health Information Technology.
On-the-ground teams and distance-teaching to facilitate clinical adoption of proven "best practices."
Advocacy:
New Communities of Practice nationally and internationally that demonstrate quality and value in healthcare.
Advocacy for changes in policy at the federal and state levels—and globally—to support new care models.
Comprehensive outreach to healthcare providers and systems, policymakers, and consumers to inform, educate, and engage.
Kim said the anonymous donor chose Dartmouth based on the university's work in health systems research and implementation, its graduate programs, history of collaboration and innovation, and the investment the trustees have already made in pursuing health reform through establishment of The Dartmouth Institute.
A spate of very large whistleblower settlements in the healthcare sector amounting to billions of dollars in fines have been reported over the last few years. For the most part, the big ticket fines are directed at pharmaceutical companies, such as Pfizer, which paid $2.3 billion last fall to settle whistleblower claims that it illegally marketed its drugs to physicians.
It would be reasonable to assume that the primary motive for whistleblowers–who are eligible for up to 25% of the recovery—is money. After all, the six whistleblowers in the Pfizer settlement split more than $102 million from the federal share of the civil recovery. Ka-ching!
"Every relator we interviewed stated that the financial bounty offered under the federal statute had not motivated their participation in the qui tam lawsuit," said the study, which focused on whistleblowers in 17 federal suits against pharmaceutical companies. "Reported motivations coalesced around four non–mutually exclusive themes: integrity, altruism or public safety, justice, and self-preservation."
The survey, led by Aaron S. Kesselheim, MD, of Harvard Medical School, found that the "most common theme" motivating the whistleblowers was personal integrity and strong ethical standards. "One relator reasoned: 'When I lodged my initial complaint with the company, I believed what we were doing was unethical and only technically illegal. This ethical transgression drove my decision. My peers could live with the implications of 'doing 60 in a 55 mph zone' because it did indeed seem trivial. However, my personal betrayal . . . so filled me with shame that I could not live with this seemingly trivial violation,'" the study reported.
"The relators in this group felt that financial circumstances helped to subvert such ethical standards in their colleagues, saying that most colleagues were unwilling for personal or family reasons to jeopardize their jobs."
The survey found that most of the whistleblowers tried to fix matters internally by speaking with their superiors, of filing an internal complaint.
"One explained: 'At first it was to the head of my department, the national sales director, and the national marketing director. . . . After being shooed aside, I went to the executive vice president over all the divisions of sales and marketing. Then eventually I went to the CEO of the company, the chief medical officer, and the president.' Insiders who voiced concerns were met with assertions that the proposed behavior was legal and dismissals of their complaints, with accompanying demands that the relators do what they were told," the study said.
Maybe some of these whistleblowers are now blowing smoke about their altruistic motives. Most of them are relatively well off as a result of their actions, 13 of the whistleblowers collected between $1 million and $5 million, and seven got more than $5 million. There may be some revisionist history going on at the poolside as they sip mojitos, admire their pedicures, and contemplate their rags to riches stories.
For argument's sake, however, let's assume that the whistleblowers' motives are pure: they saw a wrong and they made it right. As the NEJM study points out, whistleblower settlements between 1996 and 2005 let to more than $9 billion in recoveries. The federal government has said it will vigorously pursue healthcare fraud, in part, as a way to pay for healthcare reform. The fact is, their motives are almost irrelevant if your hospital is cutting the recovery check.
While the study focuses on the pharmaceutical industry, the lessons are here for everyone in healthcare. Listen to your employees. If they tell you something is wrong, they're probably not making it up. They're trying to save your hospital from millions of dollars of heartache and bad media attention. Ignore them at your peril.
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With the passage of the Patient Protection and Affordable Care Act, you can expect states to begin experimenting more aggressively with ACOs in their Medicaid programs, says Sg2 Vice President Bob Woodson. You can also expect that more large community hospital systems, academic medical centers and large physician groups will begin discussions with each other and with commercial payers about a variety of risk-sharing models, including ACOs, he says.
If you're in healthcare—or if you're just a scandal fan—you've probably been following the imbroglio surrounding Beth Israel Deaconess Medical Center CEO Paul Levy.
Levy, an avid blogger, media darling, and outspoken champion for transparency in hospital quality and costs, has been downright opaque in his public response to what he called "lapses in judgment" and what the Boston newspapers are calling an improper personal relationship with a female subordinate.
For brevity's sake—and to deflect accusations that I am piling on—I refer you to the local media, and note only that the board at Beth Israel Deaconess this month fined Levy $50,000 for his still-undisclosed lapses. They said they were disappointed in his conduct but still support him and that the matter is now closed.
So why has this scandal gotten so much attention? First, Levy is the CEO of a powerful and trusted institution. By the nature of their jobs, all hospital CEOs are held to a higher standard of conduct. As Spiderman's Uncle Ben told the super hero, "With great power comes great responsibility."
Second, Levy's calls for transparency—whether unfairly or not—raise expectations that Levy should have nothing to hide. There may be valid reasons why Levy hasn't detailed his lapses, but that doesn't quell speculation about what he did, and who he did it to, no matter how much the hospital board tells the rest of us rubberneckers to keep moving folks, show's over, nothing to see here.
Levy's lapses don't necessarily demonstrate that he is a bad guy or an incompetent leader—only that he is human. But those lapses provide us with a cautionary tale about the double-bladed nature of transparency. Don't call for transparency if your windows are dirty.
The real harm in these lapses, however, is that they corrode institutional trust from within. The public will quickly forget this relatively mild scandal, as there is always a steady stream of men behaving badly in the media: Mark Sanford, Tiger Woods, Jon Gosselin, Ben Roethlisberger, Charlie Sheen, John Edwards, David Letterman, Jesse James, etc. Take your pick.
Employees at Beth Israel Deaconess won't be so easily distracted. The Boston Globe reported that Levy's favorite female subordinate had a good job while she was with the hospital, and collected a nice severance package when she left. Of course, that has prompted grumblings–as noted by the Globe—about how this person got her job, and whether the severance package was due in some way to her relationship with Levy. I have no idea if any favoritism was shown, but those questions should be expected given the circumstances.
Levy apologized on his blog, Running a Hospital, and said he hoped "this series of events and revelations will not undercut the importance or validity of what I have been saying. I especially apologize to you if you feel that I have let you down and, in so doing, in any way weakened the case I have been making.''
Somebody told me once—on an unrelated topic—that while healthcare workers might forgive, they never forget. Could you blame any employee at Beth Israel Deaconess for being just a wee bite skeptical the next time Levy talks about the hospital's values, its openness, or its healing mission?
Levy can never again make the call for transparency and openness in healthcare with the same authority and not run the risk of ridicule. If he isn't more specific about the nature of his lapses, such as what–for example—prompted him to pay a $50,000 fine, he should probably abandon the whole "transparency" argument. Hand it off to someone who is more transparent. It's an important issue and the case must continue to be made.
Now, when Levy talks openness, it's no less true, but it's not believable.
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