Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at jsimmons@healthleadersmedia.com.
Direct-to-consumer (DTC) genetic tests now on the market may be getting ahead of the current medical science and could ironically pose health risks to those patients who may change their medical care based on those results, according to a new Government Accountability Office (GAO) study and testimony presented late last week before a House panel.
In 2006, GAO investigated several companies selling DTC genetic tests and testified that these firms made medically unproven disease predictions. Flash forward four years later: new companies have since been touted as being more reputable, but some experts remain concerned about test results be misleading consumers, the report states.
GAO purchased 10 tests each from four companies, for $299 to $999 per test. It then selected five donors and sent two DNA samples from each donor to each company: one using factual information about the donor and one using fictitious information, such as related to age, race, or ethnicity.
The results, according to Gregory Kutz, GAO's Managing Director of Forensic Audits and Special Investigations, were that fictitious consumers received test results that were "misleading and of little or no practical use."
As one example, GAO's fictitious donors often received disease risk predictions that varied across the four companies providing the tests—indicating that identical DNA samples were yielding contradictory results, Kutz told the House Energy and Commerce Subcommittee on Oversight and Investigations.
GAO's donors had received DNA-based disease predictions that conflicted with their actual medical conditions. For instance, one donor who had a pacemaker implanted 13 years earlier to treat an irregular heartbeat was told that he was at decreased risk for developing such a condition. However, none of the companies could provide GAO's fictitious African American and Asian donors with complete test results, but did not explicitly disclose this limitation prior to purchase
Marketing genetic tests directly to consumers could increase risks to patients because they may make decisions that adversely affect their health—such as stopping or changing the dose of a medication or continuing an unhealthy lifestyle "without the intervention of a learned intermediary," Jeffrey Shuren, MD, director of the Food and Drug Administration's Center for Devices and Radiological Health, told the House panel.
Since then, changes have been seen in the number and types of claims being made. For example, one company provided test results for 17 diseases, conditions, or traits in 2008; however, in 2010. it provided over 100 types of results, Shuren said. In particular, some companies are making claims about high?risk medical indications, such as determining the risk for cancer or the likelihood of responding to a specific drug.
Although the experts GAO spoke with said they believed that these tests show promise for the future, consumers should not rely on any of the results at this time, the report states. GAO says it has referred all the companies it investigated to the Food and Drug Administration and Federal Trade Commission for appropriate action.
New technical assistance guidelinesdesigned for medical providers—to assist patients with mobility disabilities—were released Thursday by the Department of Justice's Civil Rights Division and the Department of Health and Human Services' (HHS) Office for Civil Rights.
Access to Medical Care for Persons with Mobility Disabilities assists medical care providers in understanding how the Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act of 1973 apply to them.
This 19-page report includes an overview of general ADA requirements, commonly asked questions, and illustrated examples of accessible facilities, examination rooms, and medical equipment.
"It is critical that all individuals, including those with disabilities, have access to healthcare. But far too often, barriers prevent people with disabilities from visiting a doctor?s office or a clinic," says Thomas E. Perez, assistant attorney general for the Civil Rights Division.
"Due to barriers, people with disabilities are less likely to receive even basic medical treatment that will prevent routine small problems from turning into major and possibly life threatening ones," says Georgina C. Verdugo, director of HHS's Office for Civil Rights.
Title III of the ADA prohibits discrimination on the basis of disability by private hospitals, doctors' offices, clinics and other health care providers. Section 504 of the Rehabilitation Act of 1973, as amended, prohibits disability-based discrimination by all healthcare providers who receive federal financial assistance.
The new guide includes sections on exam room features and what is needed for individuals with mobility disabilities—including those in wheelchairs—to receive appropriate medical care. This calls for specifying entry door sizes, clearing floors, and specifying turning-room space. It also addresses accessible medical equipment such as exam tables and chairs and free-standing medical lifts.
For more information about the ADA or to obtain copies of Access to Medical Care for Individuals with Mobility Disabilities, click or call the ADA Information Line at 1-800-514-0301.
The Obama Administration announced on Thursday new regulations that would permit consumers to appeal decisions—such as claims denials and rescissions—made by their health plans or insurance companies.
The new regulations—issued by the Departments of Health and Human Services (HHS), Labor, and Treasury—include the right for consumers to appeal decisions made by a health plan through the plan’s internal process or through an outside, independent decision-maker. This will apply to any state where a patient lives or whatever type of health coverage the consumer has.
Grant applications from the $30 million Consumer Assistance Program will be available to help states and territories establish consumer assistance offices or strengthen existing ones. The new funds will be used to provide consumers with the information they need to select from a range of coverage options that meet their needs. It also will be used to appeal decisions by plans to deny coverage of needed services, or to select an available primary care provider of their choosing.
"If your health plan tells you it won’t cover a treatment your doctor recommends—or it refuses to pay the bill for your child’s last trip to the emergency room—you may not know where to turn," said HHS Secretary Kathleen Sebelius in a statement. The new healthcare reform act provisions "will provide patients with new rights and resources that will help ensure they get the care they need."
The internal appeals process will guarantee a venue where consumers can present information to their health plan providers.
Under the new rules, new health plans beginning on or after Sept. 23, 2010, must have an internal appeals process that:
Allows consumers to appeal when a health plan denies a claim for a covered service or rescinds coverage;
Gives consumers detailed information about the grounds for the denial of claims or coverage;
Requires plans to notify consumers about their right to appeal and instructs them on how to begin the appeals process;
Ensures a full and fair review of the denial; and provides consumers with an expedited appeals process in urgent cases.
If a patient’s internal appeal is denied, patients in new plans will have the right to appeal all denied claims to an independent reviewer not employed by their health plan. However, while 44 states provide some form of external appeal, the laws governing these processes had varied greatly.
States are being encouraged to make changes in their external appeals laws and to adopt these standards before July 1, 2011. The new standards call for:
External review of plan decisions to deny coverage for care based on medical necessity, appropriateness, healthcare setting, level of care, or effectiveness of a covered benefit.
Clear information for consumers about their right to both internal and external appeals.
Review by an independent body assigned by the state. The state must also ensure the reviewers meet certain standards, keep written records, and are not affected by conflicts of interest.
Emergency processes for urgent claims, and a process for experimental or investigational treatment.
Over the past decade, nonprofit Blue Cross and Blue Shield (BCBS) health insurers across the country stockpiled billions of dollars in surplus--while raising premiums for consumers by as high as 20% annually, according to a report from Consumers Union released Thursday.
Surplus funds, which are built primarily with consumers' premium dollars, can be used to moderate premium increases. However, Consumers Union said in its report, How Much is Too Much, that some of the financially strong BCBS plans with large surpluses have continued to seek large rate increases.
Nonprofit BCBS plans, including community owned charitable plans and subscriber owned mutual plans, held more than $32 billion in surplus by the end of 2008, according to A.M. Best.
In particular, a Consumers Union sampling of 10 diverse non-profit Blues plans found that seven of the 10 plans held more than three times the amount of surplus that regulators considered to be the minimal amount needed for solvency protection.
"These Blue plans hit consumers with big premium hikes while they've built up enormous surpluses," said Sondra Roberto, Staff Attorney for Consumers Union, in a statement. "These rate hikes could have been reduced or avoided if companies applied just a portion of their surplus to rate stability, while leaving sufficient funds for solvency protection."
The report cites several examples, including:
Blue Cross Blue Shield of Arizona raised rates for its individual market customers between 14.5% and 19.4% in 2007, 13.1% and 15% in 2008, and 8.8% to 18.4% in 2009. During that time, the company's surplus grew from $648.3 million to $717.1 million, which is more than seven times the amount that regulators consider to be the minimum necessary for solvency protection.
Health Care Service Corporation (HCSC), doing business as Blue Cross Blue Shield of Texas, Illinois, New Mexico and Oklahoma, raised rates in Texas on some individual and family plans multiple times in a year between 2007 2010. At the same time, HCSC's surplus grew from $6.1 billion in 2007 to $6.7 billion in 2009--up from $4.3 billion four years earlier in 2005; the company's surplus was five times the minimum required for solvency protection.
In one response, Blue Cross Blue Shield of Arizona said that similar to a family's savings account, it sets aside money in reserves to pay for unexpected health care claims and other expenses. "The amount we have in our reserves equals six months of expenses—an amount that ensures our future stability and ability to provide health care services to our customers," it said in a statement.
Consumers Union proposed that the companies holding excess surplus should use that money to:
Set up a "rate stabilization fund" designed to moderate premium increases going forward,
Refund policyholders the amount that they overpaid in premiums that contributed to the excessive surplus, or
Spend the money for charitable purposes like community health programs or affordable coverage initiatives.
The BCBS plans studied in the report are: Blue Cross Blue Shield of Alabama, Blue Cross Blue Shield of Arizona, Blue Cross Blue Shield of Massachusetts, Blue Cross Blue Shield of Michigan, Excellus Blue Cross Blue Shield (New York), Blue Cross Blue Shield of North Carolina, Regence Blue Cross Blue Shield of Oregon, Blue Cross of Northeastern Pennsylvania, Blue Cross Blue Shield of Tennessee, and Blue Cross Blue Shield of Wyoming.
Medical checklists are proving to be popular items in hospitals to help promote patient safety and stop medical errors. But at many hospitals, the active ingredient to transform a simple checklist into an effective tool is often missing: an energized work culture that empowers everyone who takes care of patients to speak up.
Peter Pronovost, MD, PhD, who first brought the checklist's potential in the healthcare environment to light nearly a decade ago, is first to admit that checklists will not change anything until the current medical culture changes.
In an interview in this month's HealthLeaders, Pronovost, a professor and medical director for Johns Hopkins' Center for Innovation in Quality Patient Care in Baltimore, says many of these cultures still can "contain a certain degree of arrogance, autonomy, and even fear." To change this, everyone must "evolve to a point where everyone on a medical staff can speak up and look out for the patient," he says
One group likely to agree with Pronovost is the 20-bed pediatric intensive care unit (PICU) at the Steven and Alexandra Cohen Children?s Medical New York in New Hyde Park. Earlier this month, the PICU became the first in New York State to go an entire year without a central-line infection. Key to making that goal was getting everyone on the unit—including 90 nurses and 11 fulltime faculty members—to communicate better with each other.
"Part of what we did is we changed our culture of the way that the ICU works," says Peter Silver, MD, chief of critical care medicine at the medical center. The idea was to move individuals from their "silos"—isolated groups of physicians and nurses who maintained little communication with each other.
And, it meant moving from the often patriarchal or hierarchical type relationship where what a physicians says is absolute gospel—with very little room for communication, Silver says. "We tore down all those walls."
The PICU staff actually had some concurrent assistance from its parent company, the North Shore-Long Island Jewish Health System, which began requiring all employees to participate in TeamSTEPPS—a program from the Agency for Healthcare Research and Quality and the Defense Department designed to improve communication skills among healthcare professionals when it comes to patient safety issues.
With TeamSTEPPS, the point was emphasized that "everybody on the medical team has a voice and everybody has...an obligation to use that voice to speak up in order to what is right for the patient," Silver says.
This training occurred about the same time when the PICU jointed with a nationwide collaborative effort, coordinated by the National Association of Children?s Hospitals and Related Institutions (NACHRI), in 2008 to eliminate pediatric catheter?associated bloodstream infections (CA-BSI). The initial goal was to reduce the infection rate by half, while doubling the time interval between infections.
"There were a lot of parts of the central line initiative that required a culture change," Silver says. Reducing the incidence of CA?BSI in adult patients have been successful mostly by improving insertion techniques. But with pediatric CA?BSI, the insertion of the central line is the cause of only 10% of infections, with the remaining 90% linked to "maintenance procedures" of the line.
The key to combating the infection in pediatric populations meant focusing on those maintenance procedures. The necessities of the catheter itself became a topic for discussion on daily rounds—and part an open conversation among nurses and physicians caring for the patient.
The PICU began using a dedicated nurse observer—with a checklist—who would accompany the physician inserting the catheters. The nurse would observe if safety precautions—such as hand washing or use of caps, gowns, and masks--were being implemented. If there was noncompliance with a checklist item, the nurse could stop the procedure until it was corrected.
Empowering the nurse did take some adjustment, Silver says. "Some of my physician colleagues didn't at first like it much that they would be challenged. But, we changed that culture, and now it's not even an issue.
Now, when a doctor goes in to put in a central line, "they'll go find the nurse—they seek them out," Silver adds. And similarly, nurses can report on how the central line looks--if it's functioning well or if there are concerns that it should come out.
"You have to create a sense of mutual responsibility—where you share the success. I could have talked to the entire group all of the time about how much a central line infection costs and what the mortality risk is, but that has very little impact because we deal with critically ill children," says Silver.
"It's really a matter of working on communication and creating the environment where people realize that everyone is responsible for everything that goes on with a patient—for creating the mindset that a central line infection is not acceptable," Silver says. "It's really letting everybody know that this is really important."
On July 7, the Steven and Alexandra Cohen Children's Medical New York, announced an important celebration: Its 20-bed pediatric intensive care unit (PICU) became the first in New York State to go an entire year without a central-line infection. And, it became an important milestone in a movement to use teamwork to promote patient safety.
"We're not the first unit that's done it [for a year]. There are three or four others. But it's still quite an achievement, and we're going to go for two years now," says Peter Silver, MD, chief of critical care medicine at the medical center, formerly known until this past spring as Schneider Children’s Hospital.
The achievement was part of a collaborative effort among PICUs, coordinated by the National Association of Children’s Hospitals and Related Institutions (NACHRI), to eliminate pediatric catheter-associated bloodstream infections (CA-BSI). The goal was to take what was in the literature about targeting infections and enforcing it in the PICUs, Silver says.
When the PICU started its project to eliminate CA-BSI in September 2008, the infection rate was 4.7 infections per 1,000 central line days, and it was experiencing a central-line infection every 28 days," Silver says. The initial goals was to reduce the infection rate by half, while doubling the time interval between infections.
For adult inpatient populations, efforts to reduce the incidence of CA-BSI in adult patients have been successful mostly by improving insertion techniques and using the chemical antiseptic, chlorhexidine. "We weren't that lucky in pediatrics because what our collaborative found was that 10% of the infections were associated with the catheter going in, and 90% were associated with how you took care of that catheter along the way—how you kept it sterile," Silver says.
To combat infections in pediatric populations meant focusing on the catheter maintenance procedures. The improvements included a 30-second scrub of the catheter port—what they called "scrub the hub"—with a special cleansing solution for each entry into the catheter to either administer a medication or sample blood and a new protocol for changing the catheter dressing.
But for the new patient safety procedures to work, it meant that the PICU staff need to develop a new way of staff communication to promote good patient care. The use of catheters became a topic for discussion on daily rounds with both nurses and physicians, and became a part of an open conversation among team members. "We transformed our culture," Silver says.
"Several years ago, if I were to put a central line in the patient, I would go to the bedside, and I would do it myself. Now we have a dedicated nurse observer who stands there with a checklist of all the things that I as the physician inserter must follow," says Silver. This includes hand washing, or wearing the proper mask, cap, and gown.
"Everybody on the medical team has a voice, and everybody has the right in the interest of patient safety to use that voice—actually has the obligation to use that voice to speak up in order to what is right for the patient," he says.
The results of the team approach have produced results: From July 7, 2009 to July 7, 2010, Cohen Children’s Medical Center had zero infections for 2,574 central-line days. The national average is 2.9 infections per 1,000 central line days.
And, to keep the central-line infection issue front and center in the unit, a sign is posted in the unit that says how many days it has been since our last central line infection, Silver says.
"That's the greatest thing," Silver says. When nurses come back to work after a vacation, "it's the first thing that they look at: Are we still there? Parents even look at it."
"We have over 100 staff members, from all parts of our team, who are responsible for that achievement, and it only takes one mistake to bring it back down to zero," he says. “Everybody is focused on doing everything in their power to make sure that avoidable mistakes do not happen—especially on their watch."
After nearly a year and a half of discussion, the Harvard University faculty of medicine committee released a new report Wednesday revising and clarifying the existing policy on conflicts of interest for its 11,000 faculty members. The subcommittee was part of university-wide group that simultaneously released a set of principles intended to guide the policies of all Harvard schools.
Under the new policy, the medical school will prohibit its faculty from delivering promotional talks for drug and medical device makers; accepting personal gifts, travel, or meals; and placing stricter limits regarding earning outside income. The recommended policy revisions and restrictions will be put into effect and practice starting in Jan. 1.
"Within and outside industry, many recognize that industry and academia must seek a new model of academia industry collaboration to achieve greater success at discovery and development of new treatments while fully protecting academic values and those of the medical profession," said Dean Jeffrey Flier, MD, dean of Harvard Medical School, in a statement.
"It is incumbent upon us to create a culture that is open to creative new approaches to collaboration on scientific development, based on transparency, rather than one that makes novel interactions more difficult," he added.
Harvard, like several other medical schools across the country, has come under scrutiny at the federal level in recent years over financial ties between some of its faculty and pharmaceutical and device companies. In 2008, Sen. Charles Grassley (R-IA), the ranking minority member of the Senate Finance Committee, investigated several Harvard physicians on charges that they were receiving payments from drug companies while receiving federal dollars to research that company's product.
Grassley was author of legislation, which was included in the new healthcare reform law, requiring pharmaceutical and device companies to report quarterly the money they give to physicians to the Department of Health and Human Services.
The medical school's new conflict-of-interest report follows a report issued just several weeks ago from the Association of American Medical Colleges (AAMC) that urged U.S. teaching hospitals to establish policies that manage financial
relationships between physicians and industry. Less than 1% of teaching hospitals at the time were found to have adopted policies that addressed conflict of interest in clinical care.
Among the conflict-of-interest recommendations included in the Harvard Medical School report are:
Streamlining the existing medical school conflict-of-interest policy and disclosure forms and processes.
Developing an education and disclosure-monitoring system to assist faculty with understanding the new policy and disclosure requirements.
Publicly disclosing all relevant faculty financial interests on the medical school's Catalyst Profiles website.
Prohibiting all personal gifts, travel or meals from industry, other than travel and meals in the course of allowed activities.
Prohibiting faculty participation in industry speakers bureaus or accepting compensation for a speaking engagement that limits the faculty member?s "intellectual independence" in presenting content.
Restricting industry advertising and exhibitions at continuing medical education events, and ensuring that industry programs and exhibits are marketed separately from Harvard programs.
Limiting sponsorship of a research project, regardless of the type of research, by a business in which a faculty member holds equity. (The prohibition is absolute if the business is privately held; if the business is publicly traded, then a faculty member?s financial interest in the company cannot exceed $30,000).
Prohibiting clinical research on a technology owned by or licensed to a business from which the faculty member receives more that $10,000 in annual income (down from $20,000).
Reconfirming the already existing restrictions upon guest and ghost authorship.
Are the new meaningful use guidelines enough to improve the standard for quality? Some Republican members of the House Ways and Means Health Subcommittee do not believe so and used Tuesday's hearing to challenge the meaningful use requirements. Much less is expected from the healthcare providers receiving subsidies under the new measures than what the Centers for Medicare & Medicaid Services had initially proposed.
Much less is expected from the healthcare providers receiving subsidies under the new measures than what the Centers for Medicare & Medicaid Services (CMS) had initially proposed, said Rep. Wally Herger (R-CA), the ranking Republican on the panel. Overall, the final regulations "represent a missed opportunity to improve patient care and reduce waste," Herger added.
Subcommittee Chair Pete Stark (D-CA), though, at the hearing opening disagreed—saying that "in my opinion, [the Department of Health and Human Services] took a responsible position in the final rule: The standards are aggressive, but [they] set realistic goals."
While the proposed rule initially called on eligible professionals to meet 25 requirements (23 for hospitals) in their use of electronic health records, only 15 core requirements are now mandatory for eligible providers and 14 are mandatory for hospitals—along a menu of 10 additional requirements, of which five needs to be met.
David Blumenthal, MD, the National Coordinator for Health Information Technology, told the panel that HHS will likely place greater demands on providers later on in the future.
The meaningful use standards from July 13 are first in a series of rules and will apply only to incentives payments before 2013, he said. Additional stages for rolling out electronic records will be released—and will have much more stricter requirements, he said.
"Our approach to meaningful use must be both ambitious and achievable. Like an escalator, [the Health Information Technology for Economic and Clinical Health Act] attempts to move the health system upward toward improved quality and effectiveness in healthcare," Blumenthal said. "But the speed of ascent must be calibrated to reflect both the capacities of providers who face a multitude of real-world challenges and the maturity of the technology itself."
The overall approach was to "make well-intended, capable physicians and hospitals able to get to the first step, get some help financially, get the encouragement of being able to use the record," he says. If the federal government went too low, "I think we would indeed be in danger of not getting value for money. If we went too high, we would be in danger of stifling the program right at the beginning."
The final rule released last week "lays the groundwork for establishing a robust national health infrastructure that supports the adoption of [electronic health records] that can help providers practice safer and more productive medicine," said Tony Trenkle, director of CMS's Office of e-Health Standards and Services, who also testified.
Another one of the testifiers—Eugene Heslin, MD, a physician with a small family practice in Saugerties, NY—told the panel it was important that the federal government support meaningful use because primary care physicians see Medicare-age patients two to three times more often than younger patients. He said he expects the number of those complex patients to double.
"We have to develop efficiencies and logic systems that allow us to rationalize care—to care for our patients using more intelligent tools, more efficiently—and not ration care," Heslin said. "Meaningful use moves us in that direction."
Plagiarism can be found in many types of applications—including applications to large medical residency programs, according to researchers at Brigham and Women's Hospital in Boston. In a study of 4,975 residency applications essays sent to the hospital for an 18-month period, at least one in 20 essays—and maybe more—appeared to be plagiarized.
To determine if plagiarism occurred, application essays were compared to a database of Internet pages, published works, and previously submitted essays by specialized software that returns a "similarity score" using a scale of 0-100—representing the percentage of the submissions matching another source.
An essay matching more than 10% to existing work was defined as evidence of plagiarism, according to the findings published in the July 20 Annals of Internal Medicine. The applications were received for the five large residency programs: anesthesia, emergency medicine, internal medicine, obstetrics/gynecology and surgery between September 2005 and March 2007.
"I think that for a long time people have been discussing anecdotal reports of this—a case here and there," says study co-author Scott Segal, MD, vice chairman for education in the Department of Anesthesiology Perioperative and Pain Medicine at Brigham and Women's.
Segal says he recalls hearing a presentation by an official of the National Residency Matching Program who said that only in the most egregious cases would they discipline applicants—for instance, if someone plagiarized their essay. This implied that "in their opinion, it was a rare event," he says. "But to think that one in 20 or more application essays are plagiarized, is disturbing and dismaying to us."
Segal and his co-author, Brian J. Gelfand, MD, noted in their study say that while their intent was not to pinpoint who was likely to plagiarize, several differences emerged among various subgroups of applicants.
For instance, non-U.S. citizens' essays were more likely to demonstrate evidence of plagiarism: Among foreign nationals, the rate was 13.9%; among permanent residents, 13.6%; and among others, 9.1%. Among U.S citizens, the rate was 1.8%.
Other characteristics associated with the prevalence of plagiarism included medical school location outside the U.S. and Canada; previous residency or fellowship; lack of research experience, volunteer experience, or publications; a low United States Medical Licensing Examination Step 1 score; and nonmembership in the Alpha Omega Alpha Honor Medical Society.
The reasoning for plagiarism cannot be answered with this study, Segal says. "Really all we can say is whether the material was original or not. It's very difficult to make any sort of inference to the motive of the authors of these essays."
Much literature on plagiarism discusses the variations of cultural attitudes about copying materials, he adds. "There is some evidence that different cultures may approach the copying of previously authored materials differently than they do in the West. We consider it a major academic sin to do this, whereas it may not be in other cultures."
"Another factor is that we don't know what kind of advice applicants are getting from their teachers or mentors—who themselves may be giving imprudent or ill-informed advice about writing essays," he says.
Overall, plagiarism in the applications was found among all the specialties studied and from applicants of all medical school types—even among those with significant academic honors, the researchers concluded. In the long run, they suggested that "a concerted, nationwide effort to detect and deter such plagiarism is warranted."
In a letter sent to Centers for Medicare & Medicaid Services Administrator Don Berwick late last week, 52 senators asked the agency to review its current proposal to decrease Medicare payments to hospitals—due to coding changes—by 2.9% in fiscal 2011.
The letter, which was sent several days after a similar House letter went to CMS with 242 congressmen's signatures, says that before any such a change goes into effect, "we need to confirm that the appropriate and correct methodology" has been used and that the proposed rule takes into consideration any changes in patient severity.
The letter stated that coding offsets are based on the assumption that hospital payments "have increased solely due to changes in coding or classification of patients." However, other reasons for such changes could occur such as the possibility that some patients have more serious illnesses or complex conditions.
And, as more patients are being successfully cared for in outpatients departments, those patients who end up being admitted to hospitals are more likely to be seriously ill, the letter added. Therefore, if the proposed rule is enacted, it could cost hospitals across the country an estimated $3.7 billion in fiscal 2011.
The senators cited the Medicare Payment Advisory Commission as showing that hospitals are paid "substantially less" than the cost of delivering care to Medicare beneficiaries. In fact, MedPAC projected a -5.9% decline overall for the Medicare margin for hospitals in fiscal 2010. Keeping this in mind, Congress should provide a full inflation update for hospital payments in fiscal 2011, they said.
In addition, the Medicare Inpatient Prospective Payment Rule contains a smaller-than-usual update of 2.4%, however, this would be eliminated with the proposed coding offset, the letter said. Many hospitals are reporting, though, that a 2.4% adjustment will not bring them closer this year to the actual rate of cost increases that they have faced.
If the rule is implemented, the senators are requesting that CMS ensure that the final methodology used take into account changes in patient severity. "Otherwise, this cut to hospital payments may adversely affect their ability to care for patients and serve their communities."
