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House Okays Doc Fix, Bill Sent to White House for Signature

Fri, 25 Jun 2010 13:12:00 GMT

After several days of waiting and seeing what would happen with the Senate's jobs bill, the House decided in a lopsided 417-1 vote on Thursday evening to approve the measure (HR 3962) that would postpone (until Nov. 30) a 21% cut in Medicare and TRICARE reimbursements to physicians. The approved bill was then sent to the White House for President Obama's signature.

The Senate had approved the $6.4 billion bill last Friday, but House Speaker Nancy Pelosi (D-CA) held back any vote earlier in the week in anticipation of the Senate approving the long-delayed jobs bill (HR 4213). The Senate doc fix amendment was carved out the jobs bill last week and scheduled for the separate vote by Finance Committee Chairman Max Baucus (D-MT) and Ranking Minority Member Charles Grassley (R-IA).

Hours before the Thursday House vote, Pelosi indicated at her weekly press conference she wanted to see a more complete bill from the Senate—which included extensions to COBRA unemployment benefits through the end of November and funding through June 2011 for the Federal Medical Assistance Percentages (FMAP) funding—before voting just on the doc fix.

The House had passed its jobs bill prior to the Memorial Day weekend. However, it appeared this week that the votes were not there yet in the Senate. "I'm hard pressed to pass any more initiatives here unless there's some reasonable prospect of success on the Senate side," Pelosi said.

The Centers for Medicare and Medicaid Services (CMS) began implementing the 21% cut last Friday in processing claims. However, the new bill restores the cuts back to June 1 and provides an additional 2.2% raise for physician reimbursements through Nov. 30.

After the bill was approved by the House, President Obama said in a statement that he was "pleased that Congress has acted to ensure the security of our seniors’ health care. A 21% pay cut to physicians’ payments would have forced some doctors to step seeing Medicare patients—an outcome we can all agree is unacceptable."

He also restated that a permanent fix to the Medicare formula was needed that "attacks our fiscal problems without punishing our hard working doctors or endangering the benefits on which so many of our seniors rely."

New American Medical Association President Cecil Wilson, MD, said in a statement that seniors already are experiencing access problems "as a result of the complete congressional mismanagement of Medicare over the years."

"About one in four Medicare patients looking for a new primary care physician are having trouble finding one. About one in five physicians are already limiting the number of Medicare patients they treat because of the instability and uncertainty of Medicare payment," Wilson said.

Wilson said that in December, the Medicare physician payment cut will be 23%—increasing to nearly 30% in January. "Congress is playing a dangerous game of Russian roulette with seniors’ healthcare," Wilson said. "Sick patients can’t wait. Congress must replace the broken payment system before the damage is done and cannot be reversed."

William Jessee, MD, president and CEO of the Medical Group Management Association, said that the "short term relief provided by passage" of the bill to avert the 21% Medicare payment cut to physicians "belies the fact that Congress continues to act irresponsibly in addressing the flawed sustainable growth rate formula."

He added that extending the latest payment to November will be disruptive to many medical groups. In particular, the current doc fix period expires in November—just one month before the start of the next fiscal year for most medical groups.

"It throws responsible business planning for 2011 into complete disarray and occurs exactly when physicians will make the difficult decision to participate in Medicare for the coming year," Jessee said.

In a statement, bill authors Baucus and Grassley said: "Our House colleagues deserve praise for standing with us today to help fulfill our responsibility to seniors and military families."

Looking At Medical Schools From A Different Perspective

Thu, 24 Jun 2010 15:06:00 GMT

At first glance, you don't quite believe it, when you read the findings of a recent Annals of Internal Medicine study that examined U.S. medical schools for their collective social consciousness: namely, that some of the nation's most prestigious medical schools—Johns Hopkins University, Stanford, Duke, Texas A&M, and Columbia, to name a few—are ranked near the bottom in terms of graduating physicians who continue to work in primary care, or work in underserved areas, or are underrepresented minorities.

The study, "The Social Mission of Medication Education: Ranking the Schools," bills itself as the first to evaluate U.S. medical schools, not on their academic standing, but in their ability to carry out a "social mission."

It's a study touted by its authors as groundbreaking. It's a study denounced by its critics as nothing more than a "limited picture" of medical schools.

Candice Chen, MD, co-author of The George Washington University study, contends it is important because it reveals outcomes of a medical education following graduation, in the context of social service, which she says is hardly measured in academic circles. With a primary care shortage enveloping the country, as well as greater disparities in patient populations, focusing on these issues is becoming more relevant, Chen says.

"There's such a difference between the top 20 and the bottom 20, for instance, in how many primary care physicians they graduate," Chen says. "We're not trying to berate any of the medical schools, we're just saying that in terms of social services, some schools are more successful than others, and others should learn from them."

"Primary care physician output, practice in underserved areas, and a diverse physician workforce have persistently challenged the U.S. health system and medical education," the study states. "This analysis reveals substantial variation in the success of U.S. medical schools in addressing these issues."

It found:

Public medical schools graduated higher proportions of primary care physicians than their private school counterparts.
Schools with substantial National Institutes of Health research funding generally produced fewer primary care physicians, and those in underserved areas.
Schools in the Northeast generally performed poorly in the social mission category.
Historically black schools had the highest social mission.

The researchers reviewed records of 60,043 physicians who graduated from 1999 to 2001 and completed all types of residency. The study included an analysis of data from the American Medical Association, and data on race and ethnicity in medical schools from the Association of Medical Colleges, and the Association of American Colleges of Osteopathic Medicine.

The researchers then constructed a social mission score to summarize overall performance of the country's 141 medical schools in producing graduates who practice primary care, worked in areas with a federally designated shortage of health professionals and belonged to underrepresented minority groups. In some cases, some schools are better in certain categories, but still lagged behind in overall social mission scores because of their performance in other areas.

Not everyone is happy with the study, saying that it fails to reveal the full scope of a medical education in the U.S. Others believe the information is outdated.

The American Association of Medical Colleges issued a statement denouncing the study, noting: "Like other attempts at ranking medical schools, this study falls short. By defining 'societal mission' and 'primary care' so narrowly, it provides a very limited picture of medical education's many contributions to society in the U.S. and around the world. And that serves no one well."

The study "presents a limited picture of how medical schools serve society's needs through their integrated missions of education, research, and patient care," the AAMC adds. "While producing primary care physicians, ensuring more diversity in the physician workforce, and encouraging more doctors to practice in underserved areas are important parts of that mission, they are not the only components."

SICU Psychosis: Prevent Delirium to Improve Prognosis and Stem Soaring Cost

Wed, 23 Jun 2010 15:56:00 GMT

The AIDS beat I covered during more fearful times in the 1980s and early 1990s made my usually unflappable mother extremely nervous.

She was disinterested in the science and the sociology that I'd excitedly describe, and terrorized by the possibility that transmission could become airborne, or that she could get it from sharing lunch with an infected co-worker.

"Aren't you worried that you will catch it too, given all the patients you spend so much time with?" she would ask.

Her irrational fear was so great that when she was hospitalized after a bad—and subsequently fatal—reaction to her first dose of chemotherapy in 2001, it was the threat of AIDS that seemed to haunt her the most. Her imagination went to work.

After a week or so in intensive care, her doctors extubated her and she was finally able to speak, though her voice was hoarse and histrionic.

"They were here all last night," she told me, her eyes anxious and wide with fear.

"Who, Mom? Who was here?" I asked.

"The AIDS people," she anxiously replied. "They're making an AIDS movie here, and they took over this whole hospital and they were bringing in patients to film it here," she said. "They brought in lots of gurneys with patients. There were a lot of cameras and bright lights."

They told her not to tell anyone, because they were doing this in secret. But she felt that she must, and that I should tell the doctor and get it stopped. It was wrong to use her hospital for a movie production, she complained. Lord help them if they showed her picture in any AIDS movie.

I mentioned this to the nurse, a hardened caregiver with an intensivist's mettle, who lowered her chin and closed her eyes.

"It's SICU Psychosis"—surgical intensive care unit psychosis, she replied.

"Of course we're not making a movie about AIDS or anything else in this hospital," she said, or something to that effect. "When people are this sick and in a hospital for this long, their minds become delusional."

She mumbled something about how hospital rooms without natural light disturb the patient's ability to distinguish between day and night, and their biorhythms get confused. But she really couldn't explain the cause.

"Wasn't there medication we could give?" I asked.

"No," the nurse replied. There wasn't much they could do. Would it go away? I asked. She shrugged to indicate she didn't know.

Now, it appears, researchers are stepping up efforts to understand and grapple with the problem. There's now recognition that SICU psychosis, or persistent delirium, can affect a patient's prognosis as a disease process separate from the admitting diagnosis.

Perhaps some of that new appreciation is because delirium costs a lot of money in longer lengths of stay and cost of care.

In a February report in the Journal of Hospital Medicine, Malaz A. Boustani, MD of the Center for Aging Research at Indiana University, found that patients with delirium stayed longer in the hospital (9.2 days versus 5.9) and were more likely to be discharged into institutional settings and were more likely to receive tethers during their care than patients without delirium. Also, they had higher mortality, 9% versus 4%.)

"Delirium is an all-too-common complication of hospitalization that is often unrecognized by healthcare providers, says Sharon K. Inouye, director of the Aging Brain Center at Hebrew Senior Life and Professor of medicine at Harvard Medical School. "Most importantly, delirium is often preventable." often unrecognized by the healthcare providers.

In a 2008 article in the Archives of Internal Medicine, Inouye and colleagues quantified the impact. Those who did become delirious accumulated average costs of care per day that were 2.5 times more than patients without delirium. "Total cost estimates attributable to delirium ranged from $16,303 to $64,421 per patient, implying that the national burden of delirium on the healthcare system ranges from $38 billion to $152 billion a year.

Healthcare Workers Wonder: How Did We Ever Live Without Our i-Devices?

Tue, 22 Jun 2010 17:03:00 GMT

I recently asked a group of healthcare workers "What's the one technology you can't live without?" It probably won't come as a big surprise that many of the answers began with the lowercase letter "i." In fact, some of the folks I queried sent their answers via devices beginning with that very same letter.

D. Elan Simckes, MD, medical director of Fertility Partnership in St. Louis, MO, nicknamed the iPad he got for his birthday his "MyPad."

"I thought it would be mostly used for fun, but really it's turned into an invaluable work tool," he says. "I now have all my online medical journals and my medical search engines at my fingertips at any time of the day. My iPad seamlessly interfaces with my electronic medical records system which I think increases accuracy in everything I do."

Even more important, the device has helped him overcome a condition common to physicians—poor handwriting. "There are those who say I became a doctor because my handwriting is completely illegible," he says. "My mother says it is nothing but pure chicken scratch."

Using the iPad and a dictation software application, he says he dictates everything from case notes to patient letters. "I even dictate messages to my staff and e-mail them right then. What's great is that the application is more than 95% accurate even with much of my medical terminology."

The practice's marketing department also use iPads. "They can build presentations and Powerpoints and I can instantly showcase them out in the field," Simckes says. "Last week I took my iPad to a live TV interview and had my notes right at hand. I was able to prep literally until the moment the cameras went live. The TV crew loved it and it made me incredibly comfortable and relaxed."

The iPhone has brought a little fun to the Indianapolis offices of Downtown Physical Therapy, says Bryce Taylor, president of the practice.

"Nobody could have convinced me three years ago that my patients would be playing video games for treatment," he says. "Here we are though—in a new tech era, when video games are no longer bad for you. The iPhone has helped his patients complete home exercise programs—one application has a printer-friendly handout function he uses to show patients the exercises.

"Technology certainly is making my clinic run more smoothly and creates a fun environment at times," he says.

"The smartphone is the new doctor's black bag," says John Luo, MD, associate director of psychiatric residency training at the Resnick Neuropsychiatric Hospital at UCLA Medical Center. "I never leave home or office without it."

Luo uses his phone to check medication dosages and drug interactions, sends refills online, and I looks up "all sorts of medical information using the web browser." He lists about half a dozen applications that provide him with health information, continuing medical education, and medical calculations—all at the point of care. "The smartphone is more valuable than a computer to me because it is always available to help; just as Sherlock Holmes had Dr. John Watson," he says.

And it has one more advantage over the Holmes-Watson relationship. It actually makes phone calls, too.

Note: You can sign up to receive HealthLeaders Media IT, a free weekly e-newsletter that features news, commentary and trends about healthcare technology.

It is Time to Act

Fri, 18 Jun 2010 17:26:00 GMT

With the signing of the Patient Protection and Affordable Care Act, along with the Health Care and Education Affordability Reconciliation Act, major change will be coming to the way healthcare is organized, delivered, and managed in the United States. While some information about the impact of the law is known, and some of the regulations are still being written, all healthcare leaders know one thing for certain: there will be less money to take care of more people. Healthcare leaders have been dealing with constant change for the past 30 years, but now the rate of change will need to accelerate in order to achieve success in a reformed healthcare environment.

In talking with healthcare leaders throughout the country I've come to the conclusion that organizations that move quickly and decisively to implement the changes needed will be best positioned to succeed.

The following are a baker's dozen ideas to be considered in order to position your healthcare organization for the future:

1. Strengthen your boards: Nonprofit organizations have a history of recruiting people for their boards for a variety of reasons—philanthropic, religious, community leadership—but often those reasons do not include healthcare industry expertise or business acumen from relevant industries. As a result, many healthcare organizations have missed an opportunity for these valuable business perspectives especially during a time of major change and challenge.
Recommendation: Enhance the skill set of the board to include individuals with experience in innovation, venture capital/merger and acquisition, and healthcare to strengthen the overall knowledge capital of the board. Also, consider recruiting board members from outside of your geographic area to bring new ideas and experiences into your organization. Major change may be needed for your organization and having a strong, innovative and provocative board will be an asset.

2. Change your leadership style: Leading in a stable business environment is very different than leading in a situation which requires transformational change. No matter how stable your organization is, you will need to lead it as if it were in a situation where your business and service delivery model needs to change.
Recommendation: Laser focus will be needed on three or less strategic priorities (not the 10 or so we normally try to accomplish); decisions will need to be made quicker and with less information; and an innovative/entrepreneurial leadership style will be needed to change the fundamental way business is done. Healthcare leaders at all levels should invest in such skill development—drawing from both inside and outside of the industry.

3. Make the necessary leadership changes now: Healthcare has become too insular and needs individuals from other industries to help question the status quo and move organizations forward.
Recommendation: If there are individuals on your executive and management team that are not A or strong B players, now is the time to make changes in order to recruit the necessary skills needed to move the organization forward. This creates an opportunity to recruit individuals with entrepreneurial and innovative experience, and from outside of the healthcare industry.

Senate Again Fails to Approve Fix to 21% Cut; Payment Reductions to Begin

Fri, 18 Jun 2010 13:32:00 GMT

Physicians hoping to see a postponement at last of a 21% cut in Medicare and TRICARE reimbursements faced disappointment on Thursday as the Senate failed to pass a new "doc fix" amendment to the jobs bill (HR 4213). The Senate is not likely to vote on the provision again until next week.

Thursday was significant because it was the last day that the Centers for Medicare and Medicaid Services' contractors would hold claims so that the 21% reduction would not be removed from payments made to physicians for service claims provided on and after June 1. (June 1 was the deadline for the previous extension of the doc fix by Congress.)

While CMS is expected to cut 21% on fees starting with Friday claims, providers can expect to eventually get that cut amount back if Congress approves a sustainable growth rate (SGR) fix that is retroactive to June 1. CMS also is expected to release guidance on whether it will be giving physicians permission to waive small beneficiary co payment amounts linked with a retroactive fix.

However, that action is unlikely to appease many of the major physician groups who have become increasingly vocal for a fix to permanently drop the SGR formula.

The change to the SGR proposed this week in the Senate would provide a shorter timeframe for a payment raise than the proposal under consideration last week: With the latest version, a 2.2% raise was called for physicians through Nov. 30 of this year—rather than the 2.2% over 19 months proposed in an earlier amendment. The shorter period would create in part a less expensive jobs bill (which declined from a $140 billion package the previous day to $118 billion on Thursday).

The drop in cost, however, failed to sway Republicans for supporting the bill. The jobs bill was unable to get the needed 60 votes to avoid a filibuster on Thursday: Voting along party lines, the bill eventually was defeated 56-40. The House's jobs bill—which included a 19-month SGR postponement—was passed three weeks ago.

In comments made before the Senate vote, new American Medical Association President Cecil Wilson, MD, said that implementing the 21% cut in Medicare payments will impact seniors' healthcare" as "physicians are forced to make difficult practice changes to keep their practice doors open."

Referring to the six-month delay proposed in the latest amendment, Wilson said that "continued short term actions are creating severe instability" as physicians make decisions to "protect their practices from Medicare's volatility."

The American College of Physicians, in a statement, was critical that this was the third time this year that Congress considered short-term patches to stop the payment cut.

ACP said that it initially supported an approach proposed by Congress last month that guaranteed no cuts in payments for three years—as a more permanent system to Medicare updates was considered. It said, though, it will "continue to apply maximum pressure on Congress" to stop cuts "by enacting legislation that provides stable and predictable payments—with the goal of a permanent fix."

A Shameful Silence Over Physician Exams

Thu, 17 Jun 2010 15:18:00 GMT

Each question crafted for the American Board of Internal Medicine board certification exam "is like a precious jewel," says Christine K. Cassel, MD, ABIM's President and CEO. It sometimes takes two years to form the questions, with the right precision and nuance that elicits medical knowledge sought, she says.

Cassel's not saying it's an easy test, but that if you study, you've got good chance of passing, with data showing that 88% passed the first time in 2009. That's only one of the reasons why she's "sickened and dismayed" that the ABIM has had to suspend or revoke the certifications of at least 139 physicians who "solicited and shared examination questions." The tests occurred over several years, and hundreds of questions were compromised.

What further troubles Cassel is the silence of potential exam takers, among the thousands of physicians who might have known the questions were shared and did nothing about it.

Following a six-month investigation, the ABIM cited the 139 physicians, but many others weren't cited, but may have known what was going on, and kept the information to themselves, Cassel told me. You know, the classic case of car accident scenes, where witnesses don't come forward. But here's the rub: these are physicians who didn't come forward. They were witness to something potentially wrong and did nothing about it.

"A couple of thousand people attended (the exam sessions) and not everyone stole questions, but no one alerted us," Cassel says, expressing clear disappointment in her voice. "If people see unethical behavior they should let us know." Of the people who took the tests "actually see and sign documents that they will respect the intellectual property and agree not to share any of the material of the exam," she says."It's not subtle."

The conduit for the improper action, she and other ABIM officials say, is Arora Board Review, a New Jersey test-preparation course, which apparently received copies of the ABIM test questions for several years from physicians who took the tests. Eventually the company posted test questions on its Web site. .

An " investigation revealed that (Arora) course operators repeatedly told participants that they were receiving actual ABIM questions and requested participants to send questions to the course operators after their exams," according to an ABIM statement. "As a result, any physician who ABIM has reason to believe took the course will receive a letter expressing ABIM's concern about their failure to notify ABIM about the questionable activities."

The 139 people were sanctioned for "unethical and unprofessional behavior," says Loris Slass, spokeswoman for ABIM. The ABIM's action mostly "applies to what (the physicians) did with the information after taking the exam and that undermined the certification process," Slass says.

Slass says the organization sent letters to as many as 2,700 physicians who were Arora customers who apparently did not come forward with any suggestion that actual ABIM test questions were part of the Arora Board Review list of questions. The spokeswoman would not reveal contents of the letters.

The overwhelming number of physicians weren't reprimanded, though, with Cassel believing that a line needed to be drawn to single out the particular egregious offenders, those who potentially shared dozens of questions from previous ABIM tests. There were press reports that some physicians eventually came forward, but Slass said the ABIM began its investigation through internet surveillance and not from information from Arora customers.

There were other ramifications, beyond the physicians. The ABIM, a non-profit independent evaluation organization based in Philadelphia, was forced to have workers spend day and night crafting new tests, spending countless hours and money to undo the damage. The Arora Board Review has suspended operations, and also agreed to pay undetermined damages to the ABIM.

HHS Details $250M Investment in Primary Care Workforce

Thu, 17 Jun 2010 13:12:00 GMT

Health and Human Services Secretary Kathleen Sebelius announced that the federal government has targeted $250 million to bolster the nation's primary care workforce.

The funding represents the first allocation from the $500 million Prevention and Public Health fund for fiscal 2010, created by the Affordable Care Act. Half of the fund—$250 million—will attempt to boost the number of primary care providers in this country by:

Creating additional primary care residency slots: $168 million for training more than 500 new primary care physicians by 2015;
Supporting physician assistant training in primary care: $32 million to develop more than 600 new physician assistants;
Encouraging students to pursue full-time nursing careers: $30 million for more than 600 nursing students to attend school full-time so they can complete their education faster;
Establishing new nurse practitioner-led clinics: $15 million for 10 nurse-managed health clinics to train nurse practitioners;
Encouraging states to address health professional workforce needs: $5 million for states to plan strategies to expand their primary care workforce by 10% to 25%.

"These new investments will strengthen our primary care workforce to ensure that more Americans can get the quality care they need to stay healthy," Sebelius said in a media release. "Primary care providers are on the front line in helping Americans stay healthy by preventing disease, treating illness, and helping to manage chronic conditions."

Roland Goertz, MD, a family physician in Waco, TX, and president-elect of the American Academy of Family Physicians, says the funding is "a great first step."

"It addresses the key issues. It helps us move toward the patient-centered medical home as a model of care delivery, working with registered nurses, PA nurses, and others in the system," Goertz says. "But we need to have a movement toward rebalancing. And the imbalance has been created over a long period of time. We haven't had an adequate balance of primary care physicians in this country since the 1960s. It can't just be one time for two or three years. It has to be for a sustained period of time to correct the imbalance."

Time to Break the Taboo of Wooing Well-insured Patients

Wed, 16 Jun 2010 15:48:00 GMT

You won't often overhear a hospital marketer loudly proclaim at a dinner party that their organization is trying to attract more insured patients. It's understandable—most people in healthcare got into that field to help people, and admitting aloud that you're trying to bring in wealthier clientele just doesn't seem right. This taboo needs to end now. High-value patients keep hospitals in business and enable them to care for the poor and uninsured.

I write about the strategic importance of high-value patients in the June issue of HealthLeaders magazine. The definition of a high-value patient varies depending on an organization's current business goals. It may mean a patient with insurance, a patient who uses a service line that is a strategic priority, or a patient who has been treated before and may need follow-up care—or all three.

MedStar Health, a nine-hospital system based in Columbia, MD, recently began focusing its efforts on ED patients who were not admitted and inpatients who presented with a visit to key service lines. It did this by launching a targeted direct mail campaign, a common method for reaching out to high-value patients.

"The critical thing is to identify who the high-value patients are and what strategic direction you wanted to take with them," says Jeff Miller, assistant vice president of marketing for the health system. "The key first step in the process for us was to meet with each individual hospital and determine what their business goals were and then determine what the high-value patient meant to those business goals."

DeKalb Medical, a three-hospital system based in Atlanta, also used direct mail for its ability to target specific populations and because it was a less-expensive alternative to the local media market.

Traditional media, such as TV, radio, and print advertising “is very wasteful because I can't zone in the way I really need to," said Terri Whitesel, director of corporate communications for the health system. "I could easily spend $50,000 to $60,000 a week and not get there—and with today's budgets that's not practical."

Online advertising can also be an effective way to target high-value patients, because Web sites can provide you with detailed information about their visitors, including geographic location, age, gender, and, if it is an e-commerce site, how much money they spend and what kinds of products they buy.

For their direct mail efforts, both MedStar and DeKalb use CRM software from CPM Marketing Group in Madison, WI, to segment the patient population and craft the correct messages for each audience.

This segmentation can allow you to send out a variety of messages based on age, ethnicity, gender, and incident rate.

For example, at DeKalb, a young woman who has yet to have a mammogram will receive a different postcard than an older woman who had a mammogram years ago but hasn't returned, Whitesel said. The imagery on the direct mail piece changes for each target audience, as well.

Once you've succeeded in attracting high-value patients, you must consistently continue to reach out to them to keep well-insured patients coming back. Doing so can help your organization remain profitable, which means you can continue to help those who need it most.

Seven Largest Insurers Incorrectly Pay One in Five Claims, Says AMA

Tue, 15 Jun 2010 13:20:00 GMT

Health insurers don't correctly process one in five medical claims, causing delays and adding more work, hassle, and cost to the healthcare system, according to a new American Medical Association scorecard.

The most accurately paying insurer was Coventry Health Care Inc., which had an 88.41% correct claims processing score. Anthem Blue Cross Blue Shield came out last, with an accuracy rating of 73.98% the AMA survey said. Other companies scored include Health Care Services Corporation, UnitedHealthcare Group, CIGNA Corp., Humana Inc. and Aetna, which scored in between in that order.

That's according to the AMA's latest rating of one of the 17 metrics, called the Electronic Remittance Advice accuracy, which included many of the other metrics as well and which the AMA said reflects the best overall measure of insurance company payment. Other aspects of the scoring include rate of denials, timeliness, and the degree to which health plans communicate their fee schedules to providers.

The physicians' group estimates that $777.6 million annually in wasted administrative effort could be saved if the health insurance industry improved its claims processing accuracy by even 1%. Increasing accuracy to 100% would reduce overall healthcare costs by $15.5 billion, the AMA says.

A major culprit behind the problem is the lack of standardization in insurance plan rules, because each insurer has different ways of paying for certain services, such as when multiple types of care are provided in the same office visit, explains AMA immediate past president Nancy Nielsen, MD. All too often, Nielsen says, physicians and their office staff are unaware what each insurer's plan rules are.

She gave an example of a doctor who sees a patient for a regular checkup. But the patient mentions a swollen knee that the doctor treats with a procedure known as aspiration.

"There will be two claims submitted: One for the physical and one for the knee aspiration. But the insurer will pay either nothing for one of those two claims, or half of the second, or 100% for both. But nobody knows. It's so complicated.

"Doctors end up hiring staff to deal with systems that are unique to every insurer. It's a major source of difficulty," Nielsen says.

"We want (insurance companies) to standardize those rules . . . And once that happens everybody would benefit and it clearly would reduce costs," she says. "Unequivocally in the doctor's office, you wouldn't have to have an army of people fighting with each insurer."

America's Health Insurance Plan spokesman Robert Zirkelbach suggests the blame does not lie exclusively with health plans. "A recent AHIP survey found that nearly one-fifth of all provider claims are not submitted to health plans electronically, and more than 1 in 5 claims are submitted by providers at least 30 days after the delivery of care," he says.

He adds that health plans are investing in technologies that make it easier for providers to submit electronically, to "enable doctors in these states to spend more time with their patients."

And, he reiterated a concern from his organization that according to one government report, the true villain for rising healthcare costs is "soaring medical costs–not health plan administrative costs—that are the key drivers of rising healthcare costs."

Simple 'Three Bucket' Tool Helps Prevent Huge Cause of Inpatient Death

Wed, 09 Jun 2010 16:55:00 GMT

What preventable hospital-acquired condition causes the most hospital mortality, or an estimated 100,000 to 200,000 acute care deaths a year, more than the number dying annually from breast cancer, AIDS, and traffic accidents combined?

If you answered falls or infections or medication errors, you'd be incorrect. But if you answered blood clots, by which we mean venous thromboembolism (VTE), you would be right on the money.

VTEs, including pulmonary embolism and deep vein thrombosis, are a growing nightmare for hospitals, not just because they are potentially preventable, but also because patients who survive them have inpatient costs of an additional $10,000 to $20,000 per year.

The Centers for Medicare and Medicaid now does not reimburse hospitals when they occur in hip or knee surgery orthopedic patients in inpatient settings.

Unfortunately, only about half or fewer of hospitalized patients who are at risk of VTE are getting the preventative care they should, says Greg Maynard, MD, chief of the Division of Hospital Medicine at the University of California San Diego Medical Center.

With so few hospitals looking to enact solutions, the problem is not going away. In 2008, acting U.S. Surgeon General Steven K. Galson, MD, issued a VTE "Call To Action" in which he said, "There's a big, big gap between what could be and should be, and what is," and "the majority of individuals who could benefit from such proven services do not receive them."

The report continued, "Too few health care professionals are aware of the evidence-based practices for identifying high-risk patients and providing preventive, diagnostic, or therapeutic services."

Not all VTE can be prevented, but Maynard says that 30% to 60% can be averted if the right patients are given prevention medications, and are monitored every day by a physician to make sure the patient's risk factors have not changed.

The key, he says, is to make the assessment process simple and fast, one that's built right into the admissions and transfer order sets.

That's what he and his colleagues at UCSD have developed. And so far it has successfully reduced hospital-acquired VTE incidents by 40%, and preventable hospital-acquired VTE by more than 85%.

"The last thing you want is a three-page VTE prevention order set," which he says hospital staff find difficult to use so they don't.

With funding from the Agency for Health Research and Quality (AHRQ), Maynard and colleagues tested an extremely simple "Three Bucket" tool (Venous Thromboembolism (VTE) Prevention in the Hospital: Slide Presentation) that allows hospital providers to categorize patients easily into one of three groups, based on whether they are at low, moderate or high risk of getting VTE.

The Assessment Model for VTE Risk comes in the form of physician order sheet that easily fits on a 3" x 5" index card.

"This can be completed by the physician in seconds," he says.

Low Risk – Patients under observation, with an expected length of stay less than 48 hours, patients being treated with minor ambulatory surgery or patients who are under age 50 with no other risk factors, or patients who are already on anticoagulation medications.
Moderate Risk – This moderate risk category is the largest group of patients, representing most general medical / surgery patients. Representative risk factors are congestive heart failure, pneumonia, active inflammation disease, advanced age, dehydration, varicose veins, limited ambulation, and obesity. In other words, this large category describes all inpatients not in the low or high-risk categories.
Highest Risk – Patients undergoing hip or knee arthroplasty, those with acute spinal cord injury with paresis, multiple major trauma or those undergoing abdominal or pelvic surgery for cancer.

Physicians prescribing for the patients in the highest risk category can offer more aggressive pharmacologic prophylaxis (low molecular weight heparin or fondaparinux, for example) and mechanical prophylaxis, while unfractionated heparin every 8 hours or low molecular weight heparin are offered to those in the moderate risk category.

Patients at risk of VTE with contraindications to pharmacologic prophyhlaxis are routinely placed on mechanical prophylaxis (sequential compression devices or graduated compression stockings), and education and early ambulation are offered to all patients.

A Code of Conduct for Physicians

Wed, 09 Jun 2010 14:50:00 GMT

When the American Medical Association recently released a 10-point "Code of Conduct" for health insurers, the public reaction from payers was pretty passive and politically correct.

"We do adhere to the code of conduct principles as outlined by the AMA. In fact, we have been doing so for quite some time," said Ross Blackstone, spokesman for the Health Care Service Corp. Other industry representatives issued similarly tame defenses.

But privately, some people in the health insurance industry have been much less welcoming of the AMA's 10 commandments. "I won't practice medicine if you don't practice actuarial science," one insurance consultant said.

Payers and physicians have a long history of bad blood, and the AMA's somewhat aggressive code didn't do much to improve relations.

A few of the points in the code—relating to rescissions and spending on medical services—were already covered in healthcare reform legislation. Others, such as a request for "respectful relations," seemed like vague potshots. There were, of course, valid criticisms in the code, particularly when it comes to administrative simplification and physician relations. But on the whole, it seemed like one segment of the industry simply airing its grievances with another.

What if, as a person in the insurance industry suggested to me, payers wrote their own code of conduct for physicians? Based on feedback from a few industry representatives, it might look something like this:

1. Engage in fair billing. While the majority of physicians already adhere to this point, the same could be said for insurers and some points in the AMA's code of conduct. There are, however, a few bad apples that over-bill or sometimes commit fraud.

2. Disclose conflicts of interest. "Physicians should be subject to the same transparencies as the insurers. Patients should have a right to know whether or not their physician owns the imaging center where they are sent for their CT scan, should know how much their physician is charging for their cardiac cath, etc.," says Peter Gurk, MD, medical director for Bluegrass Family Health.

3. Learn the business side of medicine. Insurers often have the best relationships with physicians who understand the business aspects of managed care and are willing to partner with their payers.

4. Embrace the evidence. The AMA requested that medical necessity be defined as care a prudent physician would provide in accordance with "generally accepted standards of medical practice." But that doesn't necessarily mean evidence-based care and could include practices that are commonly practiced but not necessarily the best option.

If a group of health plans released a code of conduct for physicians, would that accomplish anything? Probably not. And it's unlikely that the AMA's code of conduct will, either. Again, the physician organization had some valid criticisms, but the delivery of the message only makes public the wedge between the two groups.

Blame doesn't lie solely with the AMA. Both groups have to overcome a rocky history and learn to work better as partners. Gurk, who has worked both as a physician and for a health insurer, offers the best advice: "Drop the adversarial relationship on both sides."

Note: You can sign up to receive Health Plan Insider, a free weekly e-newsletter designed to bring breaking news and analysis of important developments at health plans and other managed care organizations to your inbox.

iPhone 4: Pixel Boost a Boon for Healthcare Apps

Tue, 08 Jun 2010 17:04:00 GMT

Unveiled yesterday at Apple's annual conference for software developers, the iPhone 4 is thinner, prettier, and has a longer battery life than its predecessor. But for healthcare professionals, the big news is that it shoots hi-def video and is packed with four times the pixels. Good for Farmville fans; even better for those who use medical apps, many of which rely on high resolution and advanced sharing capabilities. A few of the latest examples:

Take a test drive
Take, for example, the app for interactive, high-res surgical procedure training. One simulation replicates the challenging laparoscopic nephrectomy procedure. Urologists can practice the procedure in a virtual clinical environment without risks to patients or recurring training costs, says maker Simbionix. Course materials include featured 3D animations and interactive quizzes to test comprehension and the company plans to release more apps for a variety of procedures and topics.

Listen and learn
Thinklabs has released iMurmur 2, which lets medical students, cardiologists, and others to learn or classify patient heart sounds. The app includes digital heart sounds recordings, phonocardiograms, diagrams, and educational content. The company also has a stethoscope app that records, documents, and e-mails heart and lung sounds from the bedside or clinic.

Examine a virtual body
University of Utah researchers recently developed two iPhone applications that allow scientists, students, doctors, and others to study the human body, evaluate medical problems, and analyze three-dimensional images. Using ImageVis3D, users can display, rotate, and otherwise manipulate 3-D images of medical CT and MRI scans and a wide range of scientific images. AnatomyLab allows students to conduct a virtual dissection on images of a real human cadaver.

Search for science
Oncologists can use the CancerTrials App to research experimental therapies in clinical trials and share them with their patients. The app, released by Glaxosmithkline and Medtrust Online, starts with 12 common cancers and narrows the search by gender, age, trial status, and location. The program maps relevant studies for the patient.

Tie an electronic string on your finger
Emerging Healthcare Solutions, Inc. is working on an app that aims to reduce medication errors. Scheduled for release this summer, it will call users daily to remind them which medicine they're due to take, the exact dosage they should take, and the exact time they should take it.

Want more? Check out these previous stories on healthcare apps:

Note: You can sign up to receive HealthLeaders Media IT, a free weekly e-newsletter that features news, commentary and trends about healthcare technology.

AMA Launches Multi-Million Ad Campaign For Prompt Senate Vote to Reverse Pay Cut

Fri, 04 Jun 2010 13:35:00 GMT

The American Medical Association yesterday launched a multi-million dollar print and radio campaign to persuade the Senate to permanently reverse the 21% cut in physicians' Medicare pay before the healthcare system goes into "meltdown."

"It is sad and ironic that the senators raced home to celebrate Memorial Day without first voting to preserve healthcare for active duty military members, retirees, and their families," AMA president J. James Rohack, MD, said at a news briefing.

Already, he said, a recent AMA survey of 9,000 doctors indicates that one in five have been forced to limit the number of Medicare patients in their practice, and one in three primary care physicians have already done so. Doctors are also cutting back on staff in anticipation they are now receiving less reimbursement, Rohack said.

Rohack says the AMA will run the ads, now running in the Wall Street Journal, the New York Times, and USA Today, "as long as it's needed to get Congress to deal with this problem," he said. "The AMA will not sit silent while the Senate fails to fill its obligation to seniors and the baby boomers who begin to enter the program in just six months when the first wave turns 65."

The House voted last week 245-171 to approve a 19-month plan to stall the 21% reduction starting June 1, but the Senate left before voting and will not get another chance until Monday of next week, when it will be back from Memorial Day recess. Meanwhile, the pay cuts are in effect as of June 1.

Rohack gave an example of a real person who has already started to see the impact of the physician's pay cut.

He said the AMA just got a call from a retired nurse named Joan who needed a physician for her 72-year-old sister. "She was told that as of June 1, they were no longer accepting Medicare patients. This is a real-life example of how decisions in Washington impact real people," he said.

Rohack criticized budgetary logic in Washington, which he said seems to expect doctors to provide care that keeps people out of the hospital, relieving costs for Medicare Part A, which pays for hospital costs.

"We've provided better outpatient care, kept people healthier, done preventive screenings and that increases the Part B volumes (which pays for physicians). But there's no balance, no reconciliation of the savings of part A to pay for the increased volumes in Part B."

Rohack said that by delaying a permanent reversal of the cuts again, Congress simply digs a hole even deeper.

"Delays have only grown the problem, making it harder to fix. In 2005, physicians faced a cut of 3% and the cost of permanent reform was $49 billion. This year the cut has reached a staggering 21% and the cost of reform has more than quadrupled to over $210 billion. More delays will push permanent reform even further out of reach as the size of the cut and cost of reform skyrocket to astronomical heights."

Both the print and radio ads take the AMA's campaign to voters, urging them to call their Senators "to get back to work and fix Medicare now."

Physician-Owned Hospitals File Lawsuit to Overturn Restrictions

Fri, 04 Jun 2010 13:30:00 GMT

An association of physician-owned hospitals filed a lawsuit against the federal government yesterday in a long-shot attempt to overturn restrictions included in the recent healthcare reform bill that limit the growth and new construction of the controversial facilities.

The suit was filed jointly by Physician Hospitals of America and Texas Spine & Joint Hospital, a 20-bed private hospital in Tyler, TX, and alleges that the new law violates due process and equal protection rights granted under the U.S. Constitution.

At issue is Section 6001 of the Patient Protection and Affordable Health Care Act, which limits the development of new physician-owned hospitals or the expansion of existing ones. Although standing hospitals were grandfathered in, the law prevents them from expanding unless they meet a series of new requirements.

There are more than 300 physician-owned hospitals across the country, and 39 were under development but cannot continue because of the new law, according to PHA.

After the legislation passed, Texas Spine & Joint Hospital halted a planned expansion that had been in the works for years, says Michael E. Russell, II, MD, an orthopedic spine surgeon at the facility. The hospital had purchased nearby property and spent several million dollars preparing for the 20-bed expansion, which had already won local zoning approval.

Although the hospital will be able to remain open in the near future, hospital leaders are now unsure about its long term prospects because of the restrictions, says Russell. "How do we continue to evolve? How do we continue to take care of the patients that come in? We are going to have a huge increase in patients because of reform, and we need more access to care not less. Why would the government seek to keep a wonderful high quality, efficient, way to perform hospital services from expanding and growing?"

Accompanying the lawsuit was an injunction that would allow Texas Spine & Joint Hospital to proceed with its planned expansion.

The battle over physician ownership of hospitals has been ongoing, and similar provisions that would have restricted their development were included in previous legislation but stripped before passage. Congress also previously placed moratoriums on the construction of physician-owned hospitals.

The effort to ban physician ownership has often been spearheaded by other hospital organizations, including the American Hospital Association. While the AHA has raised questions about financial conflicts of interests and the safety of physician-owned hospitals, PHA claims that the restrictions are about eliminating competition.

“[Physician-owned hospitals] undermine the ability of full-service hospitals to continue to provide essential services as the community’s healthcare safety net," says AHA spokesperson Elizabeth Lietz.

After losing the lobbying battle, the courts may be physician-owned hospitals' last chance. The plaintiffs will try to convince the court that the law "treats physicians different than any other class of citizen," says Molly Sandvig, executive director of PHA. "Anyone else can own a hospital except a doctor. It's outrageous and not based on what this country's founded on."

But that legal argument is unlikely to work, according to Neil Caesar, president of the Health Law Center in Greenville, SC: "At first glance, it seems like they face an uphill battle. Physicians are not a protected class for constitutional purposes. They would have to show that there was no legitimate justification for the carve-out."

Using HHS Health Data: Got an App for Quality Care?

Thu, 03 Jun 2010 14:45:00 GMT

The challenge was issued just a mere three months ago by the Department of Health and Human Service (HHS) and the Institute of Medicine: Find innovative ways to distribute public health data that is local, regional, and national to help providers, patients, and local leaders across the country improve healthcare.

On Wednesday in Washington, DC, that call was met with the introduction of the Community Health Data Initiative (CDHI)—which will use free Web applications, mobile phone applications, social media, video games, and other cutting edge technologies, as HHS Secretary Kathleen Sebelius said, to "put our public health data to work."

"It's a participatory venture," Sebelius said at a briefing introducing the initiative. "This project was launched by a pretty simple belief that people in communities can actually improve the quality of their healthcare and their public health systems if they just have the information to do it—to make it happen."

"Our national health data constitute a precious resource that we are paying billions to assemble, but then too often wasting," Sebelius said. "When information sits on the shelves of government offices, it is underperforming. We need to bring these data alive."

The initiative highlighted data currently available: HHS already has posted 117 data sets and tools on the Data.Gov site since its debut in May 2009. These data sets and tools include:

Hospital by hospital quality performance statistics compiled by CMS to help inform consumer choices regarding where to get care (with additional statistics on nursing homes, dialysis facilities and home health agencies).
A regularly updated data set representing technologies available for licensing from the National Institutes of Health and the Food and Drug Administration, helpful to entrepreneurs and companies looking to drive innovation.
A household cleaning products data set that links over 4,000 consumer brands to health effects that the manufacturers are submitting and which allows scientists and consumers to research products based on chemical ingredients
Detailed summaries of Medicare expenditures on physician services, which allow the public to understand patterns of Medicare spending and analyze the types of services being delivered to address the health needs of the Medicare population.

But new efforts are being pursued as well. To promote community health data, HHS Deputy Secretary Bill Corr said that a new web-based health indicators warehouse would be launched online at the end of this year—providing data on national, state, regional, and county health performances on rates of smoking, diabetes, obesity, and other health indicators.

With the site, data will be easily downloadable and made available to other sites. The Centers for Medicare and Medicaid Services will be supplying new data to this site on disease prevalence, cost, quality, and utilization of services.

But at the introduction of the CDHI, a number of new innovations were unveiled as new examples at the briefing to show the power of public health data in providing better healthcare. The briefing can be viewed at HHS' Open Government website.

CLABSI: 'A Polio Campaign for the 21st Century'

Wed, 02 Jun 2010 15:04:00 GMT

Just before the long weekend, health providers heard some upbeat news, a fine respite from all the gloom about the sustainable growth rate and healthcare reform politics. In fact, infection control officials who attended a briefing almost sounded like they were attending a pep rally and not a press conference.

That's because it isn't every day that a federal agency can boast an 18% cut in dreaded CLABSI, or central line associated bloodstream infections, which occur an estimated 248,000 times each year in U.S. hospitals. These usually preventable infections cost the healthcare system $2.7 billion annually, and are said to be the cause of between 31,000 and 60,000 hospital deaths a year.

The good cheer was presented in the form of a document from the Centers for Disease Control and Prevention entitled the "First State-Specific Healthcare-Associated Infections Summary Data Report," an 18-page summary that examined the occurrence of these types of infections in hospitals during the first six months of 2009. What the project found was that there was a dramatic drop in CLABSI compared with the previous three years. The findings paralleled earlier reports, but included a much larger and more diverse sample of hospitals.

"We believe this decrease reflects broader implementation of CDC guidelines, enhanced tracking and measurement, and improved practices at the local level by thousands of dedicated healthcare professionals," said Arjun Srinivasan, MD, the CDC's associate director for Healthcare-Associated Infection Programs.

If there was a caveat about their sense of accomplishment, it was that the results were from a collection of data from just 17 states, which as of June 30, 2007 were the ones with laws requiring CLABSI reporting to the CDC's National Health Care Safety Network. About 10 more states have since enacted reporting mandates for these infections, but clearly what infection control leaders want is for all 50 states to have them in place. That's so they can have all the data to serve as a benchmark for future improvement.

This report included information from 1,538 facilities in those 17 states: Colorado, Connecticut, Delaware, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Oklahoma, Oregon, Pennsylvania, South Carolina, Tennessee, Vermont, Virginia and Washington. Only Tennessee and Maryland had infection ratios above expectations. Of the 15 states, 13 had fewer than expected instances and two had rates as expected. All rates were calculated based on a rate per 1,000 line days.

According to a table in the report, states that did not have reporting requirements had some hospitals that did report to the network, but in none of those non-reporting states was the number of reporting hospitals more than half. That will have to rapidly change, the researchers say.

One of the speakers at the briefing was Peter Pronovost, MD, an intensivist at Johns Hopkins University whose simple infection control "checklist" has been credited with getting many of those states' infection rates to drop. In fact, surgeon Atul Gawande reportedly credited Pronovost with "saving more lives than that of any laboratory scientist in the past decade."

The report "marks a turning point in transparency and accountability for healthcare," Pronovost said. "We now must begin to be responsible for our outcomes and no doubt these data will make some uncomfortable. We need to learn how to be accountable; to make progress we will need to collaborate and (be) coordinated."

"Central line associated bloodstream infections are the polio campaign for the 21st century," he added.

Pronovost, director of the division of adult critical care medicine at Johns Hopkins and medical director of the Center for Innovations in Quality Patient Care, pointed to the tremendous success he and infection control officials at Johns Hopkins University and at 100 intensive care units in Michigan were able to achieve by following these five steps.

Remove unnecessary lines.
Wash hands prior to procedure.
Use maximal barrier precautions.
Clean skin with chlorhexidine.
Avoid femoral lines.

He added that a key element to make that checklist work is that hospitals must "empower nurses to sop the placement of a catheter if the physicians don't comply with the checklist.

Physician Anger Rises over Congress' Failure to Meet June 1 Doc Fix Deadline

Tue, 01 Jun 2010 13:37:00 GMT

For physicians, the third time has not been the charm this year for those looking to finally get some relief from a 21% cut in Medicare and TRICARE physician reimbursements. While the House voted on Friday 245 171 to approve of a 19-month plan to stall the 21% reduction starting June 1, the Senate will not be able to act until it returns from its Memorial Day recess June 7.

With the "doc fix" approved by the House, physicians would see an increase in payment rates of 2.2% for the remainder of 2010 and a 1% increase in 2011. Rates would return to present law after 2011. This is the third deadline missed by Congress this year; the others were March 1 and April 1. In previous years, Congress had voted to delay the cuts annually.

The delay by Congress has been accompanied by sharp words from physician organizations. Last week, the American Academy of Family Physicians had expressed support for a patch proposed earlier by the House that would have extended postponement of the sustainable growth rate (SGR) formula by three years, with an increase for primary care services included in 2012 2013. But Friday, the group changed its tone over what it sees as Congress' inability to make more permanent changes in the SGR.

"Family physicians are outraged that Congress has jeopardized the healthcare security of millions of elderly and disabled Americans who depend on Medicare and TRICARE," said AAFP President Lori Heim, MD, of Vass, NC, in a prepared statement.

Congress needed to "retroactively rescind this pay cut and replace the deeply flawed SGR formula with one that reflects actual practice costs that physicians experience," she said. "The political gamesmanship must end. A comprehensive and stable Medicare payment system must be put in place."

"The American College of Physicians is deeply disappointed by Congress' recurring failure to pass legislation to stop a devastating 21% cut in Medicare and TRICARE payments to physicians," said ACP President J. Fred Ralston, Jr., MD.

Ralston, an internist in Fayetteville, TN, said that "too many members of Congress from both political parties" have declined to "support legislation to move toward a better and more stable payment system, which could have served as the basis for permanent repeal of the unworkable SGR formula."

"[Congressional members have] withheld their support even though they knew that the result will be to further undermine physicians' and patients' faith in Medicare and TRICARE," he added. "They withheld their support, even though they knew it would introduce chaos into physician practices."

ACP said that during the Memorial Day recess, it was encouraging its members to call on their congressional representatives to tell them that failure to move to "a more stable system to replace the unworkable SGR simply is unacceptable."

"Physicians and patients must let their representatives and senators know that enough is enough. Congress is wreaking havoc on the Medicare program and physician practices across the country," said American Medical Association President J. James Rohack, MD, in his blog. He called for physicians to "Make your voice heard during the Memorial Day recess."

As when Congress missed the other two deadline this year, the Centers for Medicare and Medicaid Services told its contractors to hold claims for Medicare reimbursement for 10 business days "to avoid disruption in the delivery of healthcare services" to beneficiaries and payment of claims for physicians.

Making Improved Medication IQ Part of the Treatment

Thu, 27 May 2010 16:22:00 GMT

In this era of polypharmacy—where individuals with multiple conditions take multiple medications—the route to safer, more effective care may lie with how a patient answers this question: What are you taking and how are you taking it?

As one New York area hospital found, this was especially true with outpatients at its cancer care clinic where the rising use of oral anti-cancer drugs could lead to more life-threatening complications related to drug interactions or incorrect use.

The idea of reviewing a patient's medications—finding out what they are using, when they are using them, and how they are using them—of course, is not new. The "brown bag" patient safety campaign, which has been around for years, encourages patients to bring their medications and other medical products to check-ups or pharmacy visits so providers can review their dosage and use.

But as times change, treatments and medications are changing as well. What once may have seemed like "a good idea" may be evolving into something that is a critical aspect of a patient's care. This is what sparked an initiative for outpatients at the Montefiore-Einstein Center for Cancer Care.

"Many of our patients have other co-morbid conditions such as diabetes or a heart condition," says Pragna Patel, PharmD, RPh, who is an oncology investigational pharmacy manager at Montefiore. She, along with Una Hopkins, BSN, MSN, FNP BC, a nurse practitioner with the medical oncology department at Montefiore, created the Medication Therapy Management program.

Their goal was to help cancer patients safely take their oral chemotherapy—along with other prescription medications they need for other conditions—to help avoid what could be adverse interactions or life threatening errors. The idea was to create a personalized plan to support safe and effective use and storage of their prescriptions.

The goal is to assist patients to get a better understanding of their medications—including prescribed and over the counter, along with vitamins or herbal supplements they use, according to Patel.

During their treatment, the cancer center patients are referred to the Medication Therapy Management program by the physicians and nurses for a visit with both Patel and Hopkins. During a 30- to 45-minute session, the clinical team discusses possible side effects associated with the potent anti-cancer drugs. They also will look at possible allergies or adverse reactions the patients may experience or possible drug drug or drug food interactions.