As Hurricane Irene churns up the Atlantic Coast threatening communities from North Carolina to New England, hospitals in the storm's path are working to finalize their plans for keeping their facilities safe and operational.
The Category 3 storm is expected to dump as much as 15 inches of rain in some areas.
Federal and state regulations require hospitals to have disaster plans in place. And small community hospitals and large urban health systems approach emergency planning in much the same way: they secure the facility, order supplies, get staff in place, and wait out the storm.
As of Thursday, here's how some hospitals were bracing for Irene:
University Health Systems of Eastern Carolina, Greenville, NC
The eight-hospital system has checked it blood supply to make sure it can go at least three days without a delivery. It is also moving its emergency response helicopters to an inland location. Beth Atkins, a spokesperson for the system, said all employees are on standby and every department in its hospitals has been asked to look at staffing needs through the weekend and into Wednesday of next week.
All gas meds, such as oxygen, will be topped off on Friday. And the pharmacy has stocked up and can run seven days without deliveries.
Albemarle Hospital, Elizabeth City, NC
Located just an hour from the Outer Banks, where the eye of Hurricane Irene is expected Saturday evening, Albemarle Hospital is the only hospital in a 45 mile radius and plays an important role in its community. Unlike hospitals in more urban areas, the 140-bed rural facility is often a gathering place for the community when a disaster hits.
Disabled and electricity-dependent residents come to the hospital to keep their oxygen tanks and other medical machinery running. Families of patients gather at the facility.
Patrick Detwiler, director of marketing and public relations for the hospital, said the facility orders extra supplies and food for the community. Many supplies come from other parts of North Carolina. To avoid transport problems, the hospital has stockpiled enough food and other supplies to go seven days without deliveries. In addition to clinical staff the hospital will also house housekeeping staff during the hurricane.
Peninsula Regional Medical Center, Salisbury, MD
This 363-bed hospital has an emergency operations team that has been meeting this week and will work throughout the weekend monitoring the weather and coordinating with state and local emergency management officials.
The medical center has secured its grounds to be sure there's no signage or furniture that could become airborne in high winds. A back-up generator was expected on Thursday and a 6,000-gallon potable water tanker will arrive on Friday. A 600-gallon pump to flush water from low lying areas will also be delivered on Friday. An inventory of linens and food supplies was performed and enough supplies to extend into next week were ordered.
Bayhealth Medical Center, Dover, DE
Bayhealth Medical Center expects Hurricane Irene to hit its hospitals in Dover and Milford with 75 to 100 mile per hour winds sometime Saturday night. The brunt of the storm should be out of the area by Sunday morning.
The system is required by its accreditation agency to have a plan in place to sustain itself for four days. Mike Metzing, director of plan operations for the hospital system, explained that inventories of materials, linens, medicine and food supplies have been completed and suppliers have been notified what the system will need through the beginning of next week. "Most hospitals work on a just-in-time schedule for supplies so finding storage space for all of the extra items has been a challenge."
Same-day surgeries were expected to continue through Friday but elective surgeries requiring a hospital stay have been cancelled.
Physicians have been reviewing patient records to see what patients can be discharged before the storm hits. Beginning at 6 PM on Saturday, hospital staff will begin staying at the facilities to make sure patient care continues at typical levels. A trauma team and hospitalists will also remain at the system's hospitals. An onsite daycare facility that can accommodate 30 children will be available for staff members.
North Shore-Long Island Jewish Hospital, Great Neck, NY
This 15-hospital system anticipates a direct hit by Hurricane Irene at all of its facilities sometime Saturday night. Scott Strauss, corporate director for security and emergency management for the system, said his team has been planning since Monday for the storm. With so many hospitals to consider, Strauss must be prepared for anything, including possible evacuations at some of the system's facilities located in flood zones.
Straus said the system's emergency center is up and running for about 11 hours a day. That will extend to 24 hours beginning Saturday. He said his team is preparing for power disruptions – the system will use generators – that could extend through Tuesday or Wednesday of next week.
North Shore-LIJ has hospitals in three municipalities. That means Strauss must connect with three different governments for electricity and other emergency services.
Although the system has assessed it needs in terms of supplies, linens and food Strauss said there are storage issues. He will try to coordinate deliveries as close as possible to when the supplies, etc. will be needed.
Open enrollment season for healthcare insurance is just a couple of months away and it looks like employees need to fasten their seat belts and prepare for a bumpy ride. With an eye toward cost control and new healthcare reform requirements, employers are preparing to make changes to their healthcare benefits packages. Look for more consumer-directed healthcare, more incentives for prevention and wellness, and across-the-board increases in deductibles, out-of-pocket maximums, and copayments for patient care and prescription drugs.
For providers the changes mean that patients will continue to be cost-sensitive in terms of prescription costs and medical care. Expect to see more shopping around for services like lab work and MRIs. . There will also be more of an emphasis on receiving preventive health services, such as mammograms and colonoscopies, which no longer have copayments, deductibles, or coinsurance.
But nothing in healthcare is really free, so insurers are looking to cover those lost copayments, and deductibles in other ways. In a survey conducted in June by the National Business Group on Health, a trade group of more than 300 large employers, businesses estimated that the cost of employee healthcare benefits would increase by 7.2% in 2012 or more than twice the rate of inflation.
Here's a look at some of the plan design changes survey respondents expect to implement to help with costs in 2012:
Annual benefits. In preparation for a ban on annual limits for essential benefits, employers are beginning to remove annual benefit limits for preventive and wellness services as well as mental health and substance abuse services.
Incentives. Employers are adding more services like weight management programs and increasing the average annual incentives for healthy lifestyles programs. Average incentives are expected to increase to $383 in 2012 from $303 in 2011.
Controlling costs. About 25% of the survey respondents identified increased employee cost sharing as the most effective way to control healthcare costs; 23% tapped consumer-directed health plans and 17% identified wellness initiatives as the most effective way to reduce costs.
Consumer-directed healthcare. There's growing interest among employers in adding CDHPs as an option to a benefits package. Some 56% said they will take that step in 2012. Only 17% said a CDHP would be the only option offered.
Cost sharing. About 54% of employers said they will increase the employee contribution to premiums. The spike in employees' costs will probably be less than 10%. Look for across-the-board increases in deductibles, out-of-pocket maximums, and copayments for patient care and prescription drugs.
Coverage tiers. More than one-third of employers use a four-tier design: employee, employee and spouse, family coverage, and employee spouse and children. But about 20% of employers are using a five-tier system that takes into account the number of children in a family.
Pharmacy. Most employers will continue to use a three-tier formulary design. About 15% of employers expect to increase pharmacy copays but the increases will be less than 10%. To manage pharmacy benefits, employers will continue to rely on prior authorization, quantity limits, and step therapy.
Other techniques include mandatory mail order for maintenance medications and mandatory generic substitutions.
To manage specialty pharmacy benefits, most employers will continue to use prior authorization, utilization management, and step therapy. Some 40% will use a carve-out from the health plan, while 13% will use a four-tier benefit design.
Also, 39% of the survey respondents indicated that they require employees to pay the cost difference between generic and brand names drugs.
Retiree health benefits. To control retiree healthcare costs 45% of respondents are capping company contributions, 31% are increasing employee contributions and 18% are eliminating retiree health benefits for new hires.
In addition to plan design changes, employers are doing more than simply offering healthcare benefits, through on-site health clinics and wellness programs they are getting involved in maintaining the health of their employees to help reduce costs.
Although only 37% of survey respondents said they provided on-site clinics, the services provided at these clinics has expanded. Occupational health continues to be the mainstay, but clinics are adding chronic care management, health improvement programs, and acute and primary care for their employees.
This is just the beginning of significant changes expected in benefit packages as healthcare reform is implemented.
One question on almost every employee’s mind is whether employers will continue to offer healthcare benefits once federal health insurance exchanges open for business in 2014.The good news is that 71% of companies surveyed by Towers Watson, the benefits consultant, expect to continue to offer those benefits. Only 10% have made the decision to drop healthcare coverage; the remainder are undecided.
Employers that plan to drop coverage are still exploring their options in terms of how they will help their employees access insurance. One idea being floated is to provide a salary increase equal to the cost of benefits.
Parkland Memorial Hospital in Dallas, which was cited for serious deficiencies earlier this month by the Centers for Medicare & Medicaid Services and the Texas Department of Health Services, received some good news Tuesday. Officials in the Dallas regional CMS office have approved the safety net hospital's corrective action plan.
David Wright, acting deputy regional administrator for CMS, told HealthLeaders Media that his office has authorized the Texas Department of Health Services to schedule a second review of Parkland to confirm that the CAP steps have been taken and are effective.
Parkland Memorial has until Sept 2nd to correct certain "immediate jeopardy deficiencies" in infection control and emergency department care or CMS will terminate its Medicare contract. The hospital stands to lose up to $417 million in federal funds out of its annual budget.
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This is the second time CMS has cited Parkland for a "serious and immediate threat" finding. The first was in October 2008 for a violation of the Emergency Medical Treatment and Labor Act or EMTALA.
Wright said immediate jeopardy findings are issued two or three times a year in the CMS's five-state Dallas region. "Our goal is always to get the hospital back into compliance."
Parkland still awaits word on whether the Texas Department of Health Services has approved a separate CAP to resolve licensure issues related to the CMS deficiencies. State officials did not respond to questions about the status of that review.
Even if Parkland is able to satisfy CMS and the state, it will still not be out of the woods. CMS will forward its review and the CAP to the Office of the Inspector in the U.S. Department of Health and Human Services to determine if any fines will be levied related to EMTALA violations.
Ron Anderson, MD, and CEO of Parkland Health and Hospital System, declined to comment until the health system receives official notification of the CMS action.
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Federal and state officials performed an eight-day onsite review of Parkland Memorial Hospital in July and identified problems in nine broad categories, including infection control, governance, emergency room care, and medical screening. The hospital was notified of the problems and given two weeks to develop a corrective action plan to resolve the issues.
Following the announcement earlier this month of a $1.8 million False Claims Act settlement with the Department of Justice, Maryland's Peninsula Regional Medical Center said Monday that it will retain an independent review organization to evaluate and analyze the medical necessity of procedures performed in its cardiac catherization lab.
The move is part of a corporate integrity agreement the medical center signed as part of its deal with DOJ to settle a case in which prosecutors said unnecessary cardiac stent procedures were performed by a Pensinsula cardiologist.
The CIA was signed August 9 but wasn't released to the public until Monday when it was posted on the website of the Office of Inspector General.
The document details the steps officials at the Salisbury, MD medical center will take to ensure that the operation of its cardiac cath lab complies with federal and state regulations.
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The IRO will review random catheterization lab procedures to assess the appropriateness of case selection, execution of the procedure, and the response to any problems.
The fraud case involved allegations that officials at PRMC knew about, but failed to act on, unnecessary cardiac stent procedures performed by John R. Mclean, M.D., a cardiologist at the medical center. McLean was convicted of fraud in July 2011 after federal prosecutors showed that he inserted unnecessary cardiac stents into more than 100 patients as part of a scheme to defraud government and private insurers of more than $700,000.
Because of the impact on the quality of patient care, the OIG required that the corporate integrity agreement include independent quality monitoring to review PRMC's delivery of care and to evaluate its ability to prevent, detect, and respond to patient care problems.
PRMC must comply with the terms and scope of the CIA for five years. A material breach of the CIA requirements could result in Peninsula being denied access to federal healthcare programs.
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In addition to independent review and quality monitoring the medical center agreed to:
Appoint from senior management a compliance officer who will report directly to the CEO and be responsible for developing and implementing the policies and procedures needed to meet the CIA requirements.
Appoint a board-certified cardiologist to serve as the medical director of its cardiac cath lab. The director will be responsible for the clinical management and oversight of the lab and will file a quarterly management report to the physician executives and compliance officer.
Appoint up to three physician executives who will be responsible for medical staff quality matters
Appoint a peer review consultant to assess peer review, credentialing and privileging
The policies and procedures developed by the compliance officer must address the management and oversight of the cath lab, including recordkeeping for all procedures performed, tracking the volume of cath procedures performed by each physician, and comparing results to national benchmarks.
"Working with the government and fully cooperating with all reviews has culminated in an agreement that strengthens our compliance program. Our standards of accountability were exhaustively reviewed, enhanced and are now more comprehensive than at any time in our 114 year history," said PRMC President and CEO Dr. Peggy Naleppa in a media statement released Monday.
At a specially called board of managers meeting Friday, officials at Parkland Health and Hospital System in Dallas, TX unveiled a corrective action plan to address deficiencies that federal officials said represent “an immediate and serious threat to patient health and safety.”
The plan addresses deficiencies discovered during an eight-day review conducted by the Centers for Medicare & Medicaid Services and the Texas Department of Health Services. If unresolved, the problems at Parkland Hospital could cost the system some $417 million in Medicare and Medicaid funds out of its annual budget.
Problems with infection control and emergency room care were among nine broad categories of deficiencies discovered in July at the safety-net hospital during the review. State health officials requested the review following the death of a patient in Parkland’s psychiatric emergency department. The hospital had failed to report the death to federal and state regulators as required by law.
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In an August 9th letter to the health system’s CEO, Ron Anderson, MD, officials at CMS identified deficiencies and gave the health system until August 24to develop a corrective plan.
The letter said that because of the deficiencies, the health system “no longer meets the requirements for participation in the Medicare program,” and it warned that failure to submit acceptable plans of correction would result “in your termination from the Medicare program effective Sept. 2.”
Because the Medicare and Medicaid programs have similar requirements, Medicaid funding also was in jeopardy, the letter noted.
According to media reports, this year Parkland expects to receive about 50% of its patient revenue – or $226 million – from Medicare and Medicaid payments. It also receives about $191 million in Medicaid disproportionate share subsidies. The total from both programs – $417 million – represents about 35 percent of Parkland’s total annual budget.
With the letter, CMS and Texas officials released to the hospital more than 600 combined pages detailing their findings. The reports, annotated by Parkland to indicate corrective measures, were made available to the public Friday evening.
Failure to dispose of soiled gloves and gowns and wash hands after treating patients
Failure to properly dispose of infectious waste, including used syringes, body fluids, used respiratory equipment and used suction equipment
Lack of stabilizing treatment in emergency department before a transfer to another acute care facility
Lack of ER screening by a qualified medical professional
Failure to identify or assess emergency severity index
Medical residents unsupervised during clinical care by either an attending physician or faculty member
ER patients in a high level of pain provided with maps and directed to go to other parts of the hospital for treatment without benefit of any other assistance
Failure to provide 24-hour nursing services
Failure to change bed linens between emergency room patients
Failure to dispose of expired medications
Hospital officials separately addressed each deficiency and identified the steps Parkland Hospital will take or has already taken to correct the problems, including:
Requiring medical screening for every patient entering the ER
Revising medical staff rules to require medical screening to be performed by a qualified medical professional
Requiring transfer certification and consent and a memorandum of transfer be completed for any ER patient transferred to another facility
Assigning escorts to help patients move from one section of the hospital to another
Implementing a medical management bar coding system to managing supplies and drugs
Hiring at least 10 additional nurses
Enforcing infection control procedures to reduce contamination
Setting up preventive maintenance program to keep equipment in working order
In statement posted on Parkland’s website on Friday night, CEO Ron Anderson provided some additional insight into the steps the hospital is taking to rectify the issues cited by CMS and the state. “Mandatory training and re-education is under way for all employees and medical personnel. Monitoring of employee practices for compliance has begun. For instance, infection prevention education sessions are being held every hour, on the hour for six days to reiterate the proper disposal of personal protective equipment and hand hygiene.”
CMS will review the corrective action plan this week. If approved, another review will be conducted before Sept. 2. In an interview with the Dallas Morning News, David R. Wright, acting deputy regional administrator for CMS explained that after the second review “If the immediate jeopardy continues or there is identification of new immediate jeopardy, the hospital will be terminated on September 2. If inspectors determine there is no longer any immediate jeopardy to patients but that some problems still exist, CMS would issue Parkland another plan of correction deadline.”
This promises to be a big week for healthcare reform - no, not in the courts - but in the regulatory realm. All eyes are on the Centers for Medicare & Medicaid Services, which is poised to release the final rules on accountable care organizations,
And Friday marks the deadline for organizations to apply to be part of the Pioneer ACO program. That's the special designation CMS has set up for healthcare systems that are already experienced in providing coordinated patient care. CMS hopes to have 30 Pioneer ACOs in place by later this year, 'all on an accelerated track to participate in shared savings.
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According to the HealthLeaders Media Industry Survey 2011, more than half, (52%) of physicians surveyed said they expect to be part of an ACO within the next five years. That survey, however, was completed months before the proposed rules were released in April.
'With upfront costs reportedly running in the millions of dollars, uncertainty about how much control anyone will have over their patient population, and concerns about meeting anti-trust requirements it's no wonder that ACO participation is still a big question mark for a lot of organizations.
This has to be white-knuckle time in CMS administrator Don Berwick's office. If the Pioneer ACO program can't attract health systems that are experienced in care coordination, how can it expect other groups to sign on?
Stephen Shortell, PhD, dean of the School of Public Health at the University of California, Berkeley, recently co-authored a commentary about implementing ACOs for the Journal of the American Medical Association.
In an interview with HealthLeaders he noted that the big hurdle for many hospitals and physicians is that ACOs will require each of them to move from their comfort zones into new relationships with new responsibilities. Success will require adaptation and change. ACOs will need to become to become "learning organizations that can comprehend and expand what works and move to correct things that do not."
Shortell identifies 10 common mistakes made by organizations considering the formation of an ACO. He said he developed the list after speaking with stakeholders across the country.
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The blunders fall into two large categories--health systems overestimate their organizational capabilities and they underestimate the effort it takes to engage stakeholders.
On the organizational side, he said there's a tendency to underestimate risk and overestimate the capabilities of electronic health records. Looking at stakeholders, he said health systems underestimate the effort it will take to balance their needs with those of physicians and specialists, as well as the effort it will take to engage patients in care coordination.
'Shortell says the list below applies both to ACOs planned with CMS and those planned with private payers, which are also known as "commercial ACOs".
1. Overestimating the ability to manage risk. Shortell said this is especially true when rewards are at stake. The problem is that physicians and hospitals manage different types of risk. Physicians manage risk in ambulatory care settings while hospitals manage risk on inpatient care settings. The Medicare shared savings program requires the ACO to manage risk across the care continuum. That means hospitals and physicians must each give up some control and merge their risk-taking capabilities. That's not a step that comes naturally.
2. Overestimating the ability to use EHR.
The financial support of CMS definitely eases the pain but Shortell said the implementation of EHR can be very disruptive to a physician practice with the negative impact stretching out for six months to a year. He cautioned that a successful EHR launch requires the ongoing staff support of physician or nurse, software upgrades, and regular staff training. What's at stake is the ability to report on the cost and quality metrics required for shared savings success.
3. Overestimating the ability to report performance measures.
Even with EHRs it will be a challenge to collect, analyze, and report the 65 performance data measures that may be required of ACOs.
4. Overestimating the ability to implement standardized care management protocols.
The goal of disease protocols is to eliminate anything in the care delivery process that doesn't add value. For protocols to work, clinicians must be involved in their development, data must exist to assess the protocols, and the protocols must be able to be tailored to individual patients. Everyone in the ACO needs to use the protocols, which should be adjusted over time as more information becomes available. This process needs to be managed by someone and not just left to chance.
5. Failure to balance the interests of hospitals and physicians.
The jury is still out on whether new incentives like shared savings will mitigate or exacerbate the strain that usually exists between hospitals and physicians.
6. Failure to engage patients in care management.
Patients need to be a key part of the care team and educated to take responsibility for their health and healthcare. Unfortunately that's not a skill that seems to come naturally to either hospitals or physicians.
7. Failure to have contractual relationships with cost-effective specialists.
Specialists and patients will not be limited to a single ACO so referral relationships will be very important in terms of overall ACO performance. Shortell said PCPs may need to reexamine their entrenched relationships with high-cost specialists that don't produce the quality improvement measures necessary for a successful ACO.
8. Failure to navigate the new regulatory and legal environment.
Compliance with new regulatory requirements will require new levels of transparency and cooperation among hospitals, physician organizations, and payers. Lawyers need to be involved.
9. Failure to integrate beyond the structural level.
Structural and contractual relationships may be in place on paper to provide more coordinated care, but if behavior doesn't change, then the structure is meaningless. Improvement will require engaging all of the healthcare professionals along the care continuum in the process.
10. Failure to recognize that everything is interrelated.
It's almost a domino effect. Overestimating the ability to manage risk will be exacerbated by the failure to implement EHRs, which will limit the ability to develop and report performance measures. That could make it more difficult to balance the interests among hospitals and physicians, which could lead to a failure to engage patients and a difficulty in developing contractual relationships with cost-effective specialists. And so on and so on.
That could mean your ACO would fail to reduce preventable hospital readmissions, eliminate admissions for asthma and diabetes, reduce inappropriate emergency department use, or improve the overall patient experience of care. And that could mean no shared savings.
What needs to happen, says Shortell, is that potential ACOs need to develop a strategy to address these possible mistakes. The best way is to develop a system of rapid feedback so that performance can be corrected along the way well before mistakes begin to affect the entire organization.
The key he says is to keep moving forward. "This isn't an overnight process. We're probably 10 years away from seeing a marked difference in how healthcare is delivered. This is just the beginning."
A few years ago, a new primary care physician explained to me that among her many services she could also write my prescriptions for any drugs I might need, including , she said, antidepressants.
Her offer surprised me. I told her that if I were taking an antidepressant, I would to also need therapy care from a psychologist or psychiatrist. She explained that antidepressants are prescribed for everything from anxiety to weight control and that she was very confident in her ability to match the pill with the patient.
I thought about that conversation this week when I read a study about the increase in antidepressant prescribing by primary care physicians. According to the studying the August issue of Health Affairs, these medications are routinely prescribed by PCPs for uses that may not be supported by clinical evidence. "Many people view psychiatric medications as enhancers of personal and social well-being, providing benefits well beyond these medications clinically approved uses," the study says.
Analyzing office visit data from 1996-2007 compiled by the Centers for Disease Control and Prevention, the study found that more than 9% of PCP visits resulted in prescriptions for antidepressants, but in only 44% of those cases was there a diagnosis of depression or anxiety disorder.
The typical patient who gets a scrip for antidepressants is more than 50 years old and has a chronic condition – such as diabetes, hypertension, heart disease or asthma ?? that may contribute to symptoms of depression.
Big bucks are involved. Antidepressants are the third most commonly prescribed medication class in the U.S. with annual sales of about $10 billion.
That's money that health plans are spending on care that may not be necessary or could be treated with less expensive drugs. With billions of dollars in play, this prescribing trend has ramifications for public policy and health plan bottom lines.
In a telephone conversation, Ramin Mojtabai, a public health researcher at Johns Hopkins who co-authored the study, stressed that there is no evidence of inappropriate use. "We're just seeing more use of antidepressant among people who may have only vague symptoms like stress or maybe relationship problems."
My doctor was right when she clicked off a list of uses for antidepressants that didn't include, oddly enough, depression.
According to the study, antidepressants are increasingly associated with problems such as tiredness, smoking problems and headaches. Mojtabai noted that there's little evidence that antidepressants have any effect on these conditions or on milder episodes of depression or anxiety for that matter.
He said there's concern about physician followup. "We don't know if patients are referred to specialists or if they just continue to take the drugs because they are prescribed. Some patients may just stop taking the meds and encounter side effects."
Mojtabai pointed to a couple of reasons for the increase in PCP's prescribing antidepressants. A shortage of mental health professionals and a lack of insurance coverage top the list. And some people would rather ask their PCPs for these medications than seek the care of specialists, such as mental health practitioners.
In the study, Mojtabai and his co-author, Columbia University psychiatrist Mark Olfson, suggest that the new provider arrangements such as accountable care organizations will encourage more care coordination between primary care physicians and specialists, including psychologists and psychiatrists. That could help get antidepressant use back in line with clinical efficacy.
The study also makes two chief recommendations to help reduce the frequency of the prescribing of anti-depressants without a psychiatric diagnosis:
Improve provider education on how to recognize mental disorders, the treatment limits of antidepressants and the long-term effects.
Change drug formularies for antidepressants by creating cost-sharing tiers linked to diagnoses. Cost sharing would be less for patients who are prescribed the medications for recognized clinical conditions.
Mojtabai, who has studied the use of antidepressants for several years, says any policies should also look at how to make sure the drugs get to the people who really need them. "That's the paradox I've seen. Prescribing has increased but the people who really need antidepressants aren't getting them."
A rule proposed by the Centers for Medicare & Medicaid Services to allow Medicare and private sector claims data to be used to produce public reports that evaluate the performance of physicians and other healthcare providers raised a number of red flags among the 40 public comments submitted so far. The comment period ends tonight, Aug. 8, at 11:59 p.m.
Among the concerns: the criteria for the qualified entities that will compile the data, the ability of providers to contest the produced reports, and privacy. The comments filed were primarily individual physicians and specialty groups such as the American Association of Orthopaedic Surgeons. Some business groups, including the Business Roundtable and the National Business Group on Health, also filed comments on the proposed rule, Medicare Program:Availability of Medicare Data for Performance Measurement, docket ID CMS-2011-0122.
The rule is an effort to standardize quality measurement in a way that influences providers to improve the standard of care they deliver. Although the comments reflect general support for quality measures, with only a few exceptions the statements are focused on the mechanics of process and not whether the rule will improve care.
Here’s a sampling of the comments posted on regulations.gov:
Anonymous from Texas said: “This proposed rule will drive physicians to a race to the bottom by providing the least costly, but not necessarily the most innovative treatment for their patients.”
Robert Rubino, who is identified only as being from New Jersey, expressed doubt that an agency the size of CMS can react with any speed to new technologies and protocols that may improve the quality of care delivered. “The premise that a government entity that is so poorly run, such as Medicare and Medicaid, can assess quality of care is ludicrous. By the time Medicare recognizes new technology as a standard of care it is often already obsolete. Physicians constantly hone and perfect their care based on peer reviewed journals, shedding old protocols while adopting new ones. The slothful behemoth of CMS could never keep up with them. To simply apply a change in a treatment paradigm on the CMS side would take months or years for it to filter through the bureaucracy.”
Charles Groves, a physician in Indiana, suggested that the rule might mean he could no longer serve some patients. “If I am going to be evaluated by the expense of lab/x-ray/hospitalization costs, then I will need to fire patients with expensive, chronic medical problems.”
The American Association of Orthopaedic Surgeons, which represents more than 18,000 orthopedic surgeons, asked that the experience requirements be strengthened for organizations interested in accessing the Medicare data. “The AAOS believes that qualified entities should have a minimum of five years experience in performance metrics and prior use of Medicare or other payer claims data, not the currently proposed three years. We also believe that organizations should have a concrete plan to furnish data to providers and patients that is reliable, accurate, and actionable.”
In addition, AAOS recommended that providers be given 60 to 90 days to review any reports before they are made public. “We also urge CMS to require qualified entities to supply providers with a more granular report that is easily obtained and can actually be reviewed for discrepancies.”
The American Psychiatric Association, which represents more than 37,000 psychiatric physicians, cited the need to punish any organization that violates patient privacy. “The APA endorses requiring approved qualified entities to execute a data use agreement before receiving any CMS data. Where qualified entities misuse or leak a Medicare beneficiary’s identifiable healthcare data, the APA asks for immediate termination of the qualified entity’s access to any CMS data, followed by the imposition of civil monetary and criminal penalties, as well as provider notification of the breach.”
In its comments The American Chiropractic Association expressed concern about the quality reporting data being captured by CMS for doctors of chiropractic. “Because there is only one service provided by doctors of chiropractic that is covered by Medicare DCs are extremely limited in the quality measures for which they can report. Although DCs are licensed and trained to provide evaluation and management services, radiologic and diagnostic service, physical medicine and rehabilitation services and other procedures, DCs cannot report on any quality measures related to the provision of those services. Now that that PQRS quality measures will be the basis for the reports disseminated by qualifying organizations, the data for DCs will be extremely limited. When compared to private insurers there will be no comparable Medicare data for the services that DCs provide, aside from spinal manipulation.”
The American College of Cardiologists, a40,000-member nonprofit medical society, commented that physicians are not allotted sufficient time to review and comment on the data released. “While physicians are given an opportunity to review the data, CMS only proposes as little as a 10-day period in which to review what may be thousands of records covering a period of two to three years.
This is not nearly enough time to review data and point out errors to the qualified entities. In addition, the rule is unclear on what happens if a physician or other provider does identify problems. The ACC urges CMS to provide a longer period for physicians and other providers to review data and a specific action plan for the qualified entities if a physician or other provider identifies an issue.”
The American Academy of Neurology, which represents 24,000 neurologists and neuroscience professionals, requested that CMS “specify requirements surrounding whom physicians can be compared to and rated against. For example, QEs should compare physicians in their reports matched by how often they work full or part?time, whether they practice in an urban or rural environment, the severity of the patients they treat, and what part of the country they practice in (the state or metropolitan statistical area).”
The Business Roundtable, an association of CEOs representing more than 35 million employees, retirees and dependents, asked CMS to provide an option so that qualified entities with less than three years of experience in performance metrics could be included in the program if they have “sufficient experience in other related areas.”
The group supports limiting the correction and appeals process to 30 days. “We certainly agree that providers must have the opportunity to identify and correct errors in the report prepared by the QE. Indeed, inaccurate data can cause harm. By the same token, however, the correction and appeals process should also not become an open-ended process that may inadvertently create incentives or opportunities for certain providers to use these procedures to block or delay issuance of an accurate report that shows marginal or poor performance by the provider.”
Inland Northwest Health Services, a Spokane-based nonprofit that provides information technology and quality measurement services to rural healthcare providers, said some of the rule requirements would limit participation by rural healthcare organizations. “Historically rural regions have been served primarily by the two government payment programs, Medicare and Medicaid, and a very limited number of private payers. Those private payers have been reluctant to share claims information as it could reveal too much about their cost and payment models. By limiting participation in this new program to organizations that have extensive multi-payer experience, CMS will essentially be disenfranchising rural healthcare providers and the organizations that serve them. To address this issue, we strongly recommend that CMS allow organizations with experience in rural healthcare systems to participate by partnering or contracting with others that have more experience in claims data. This approach will ensure that rural healthcare organizations will have affordable access to this new information while also assuring that CMS’ methodological concerns are addressed.”
The National Business Group on Health, which represents 330 large employers who provide healthcare benefits for 50 million employees, retirees and dependents, said that despite the rule’s good intentions it “goes against the congressional intent and spirit of the law by unnecessarily narrowing consumers’ access to the data and limiting the ability of organizations to conduct innovative analyses of the data to improve consumer choice and providers’ performance.”
Noting that the proposed rule “restricts the release of Medicare claims data to qualified entities that agree to release their evaluations of providers’ performance to the public,” the business group asked CMS to “consider alternative access for employer-sponsored plans that want to use the data for internal purposes only (provider network contracting, pay-for-performance, value-based benefit design, value-based purchasing), with less stringent requirements than for qualified entities since they will not publicly report this information.”
The 34-count indictment alleges that Paul Petre, MD, of Rochester Hills; Anmy Tran, DPM, of Macomb; Mark Greenbain, MD, of Farmington Hills; and Mustak Vaid, MD of Brownstown Township, received kickbacks and other inducements as part of a scheme that involved writing patient prescriptions for unnecessary medications, billing insurers for the unnecessary care, and directing their patients to fill the prescriptions at more than 20 pharmacies throughout Michigan owned by Babubhai "Bob" Patel, a Canton pharmacist.
Patel, along with other pharmacists, business associates, and patient recruiters are also listed in the indictment.
The Patel pharmacies billed insurers, including Medicare, Medicaid, and private insurers, for dispensing the prescribed medications, despite the fact that the medications were medically unnecessary and/or never provided, according to the U.S. Drug Enforcement Agency, which worked with the FBI, HHS’ Office of Inspector General, and local authorities.
In addition, Patel and his pharmacists are charged with dispensing controlled substances to patient recruiters as a kickback for recruiting patients into the scheme.
Over the life of the alleged fraud activity, which began in January 2006, the Patel pharmacies billed Medicare and Medicaid at least $37.7 million and $20.8 million, respectively, for medications that were either unnecessary or never delivered to the patient, according to authorities.
The pharmacies dispensed at least 250,000 doses of Oxycontin, 4.6 million doses of Vicodin, 1.5 million doses of Xanax, and not less than 6,100 pint bottles of codeine cough syrup, according to the DEA.
The indictment is part of a stepped up efforts by the Department of Health and Human Services to uncover fraud in the Medicare program. "The diversion of prescription medications coupled with the fraudulent billing of Medicare creates a toxic scenario that can place a individual's health and safety at risk as well as taxpayers dollars" said Lamont Pugh III, special agent in charge of the Chicago region for HHS’ Office of Inspector General, in a press statement. "The OIG will continue to work with our law enforcement partners to hold those who seek to harm the Medicare program accountable.
Legislation to reauthorize the funding for the Children's Hospital Graduate Medical Education program is now expected to be considered in a Senate committee when Congress returns after Labor Day.
What's at stake is $330 million in funding to help cover the cost of 5,600 pediatric residencies at 56 free-standing children's hospitals across the country, which train 40% of the nation's pediatricians and 43% of pediatric sub-specialists. A spokes person for one children's hospital, which did not want to be identified, said the funding is necessary to support the training for certain pediatric specialties that remain in short supply. She noted that a five-week wait for an appointment is not unusual for pediatric specialty services in pulmonology, neurology, and endocrinology.
Supporters had hoped that S 958 would pass out of Senate Committee on Health, Education, Labor & Pensions (HELP) this week, so that it could be scheduled for a Senate floor vote early in September. Instead the bill will have a mark-up session in the HELP committee on Sept. 7—just three weeks shy of the expiration of it current appropriation.
The House companion bill, H.R. 1852, passed out of the House Energy and Commerce Committee in late July. A full House vote of that bill was delayed while the Congress debated the debt ceiling.
HealthLeaders Media contacted the HELP offices in an effort to identify a timeline for the Senate bill but staffers declined to comment on a potential time period when S 958 might go before the full Senate. Efforts to reach a spokesperson for the House bill were unsuccessful.
Timing is critical, say advocates, because CHGME funding was cut from the Obama administration's budget for fiscal year 2012, which begins Oct 1. That means Congress would need to act quickly to reauthorize the program and provide an appropriation. The administration reportedly wants to redirect the CHGME funding to train additional primary care physicians.
Although supporters are growing confident of passage of the reauthorization bill, CHGME must still pass muster with the Congressional appropriations committee. There also is concern regarding the role the debt super committee will play in budget negotiations.
Jim Kaufman, vice president for public policy for the National Association of Children's Hospitals, explained that the House and Senate bills will both reauthorize the program for five more years but that as discretionary spending, CHGME funding will still be subject to the annual appropriations process.
Funding for individual hospitals in 2010, the latest year figures are available, ranged from about $51,000 at Children's Specialized Hospital in Mountainside, NJ, to the more than $21 million received by both Children's Hospital of Philadelphia and Boston Children's Hospital.
Amy B. Mansue, president and CEO of Children's Specialized Hospital, said if funding for the program is trimmed or cut that most affected hospitals will try to find a way to maintain their pediatric residency programs. “The biggest loss would be to our patients who would not have access to the specialists who have the skills to help children reach their fullest potential.”