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What Breast Cancer Screenings Reveal about Cost Control

Thu, 19 Nov 2009 16:23:00 GMT

Sometimes changes to cancer screening recommendations are actually just changes to cancer screening recommendations. But judging by the backlash against new breast cancer screening guidelines released this week by the U.S. Preventive Services Task Force, sometimes they represent deeper problems and frustrations with the healthcare system.

After reviewing literature on the effectiveness of mammograms and other screening methods, the USPSTF recommended against routine mammography for women 40 to 49 years old and suggested women 50-74 get a mammogram every two years. Previous guidelines recommended annual mammograms for women over 40. The study found insufficient evidence to assess benefits for women over 75, and the task force recommended against teaching breast self-examination.

Some see this as an initial foray into the realm of comparative effectiveness research, which the Obama administration hopes will improve care and keep costs down. If that's what it is, the road ahead will be bumpy, judging by the reactions.

Both physicians and patients came out firing at new guidelines. Some patients saw it as a denial of services and worried that their cancer will go undetected. Officials with the Access to Medical Imaging Coalition and the American College of Radiology flamed these fears with borderline fear-mongering language when they warned that "countless American women may die needlessly from breast cancer each year."

Not everyone was critical, however. The National Breast Cancer Coalition applauded the decision and has for more than a decade argued that there has been too much emphasis on breast cancer screening. The USPSTF report claims that screening every other year is just as effective as screening annually, and it reduces the false positives or overdiagnosis rates, which can be as high as 10%.

I don't have the clinical expertise to evaluate the soundness of the guidelines, but I think this episode illustrates the difficulty in implementing comparative effectiveness guidelines and the real cost conundrum facing U.S. healthcare.

Consider how patients, physicians, and the government approach the problem:

Patients
What they say: Cancer terrifies most people. When a physician tells a patient that a specific test or procedure isn't needed 99 times out of 100, the patient's mind is usually focused on the one time that it is necessary. That 1% may be statistically insignificant to a researcher or clinician, but to the rare patient whose cancer goes undiagnosed it represents the difference between life and death. It's hard to argue numbers when someone is facing the potential end of their entire existence. The big question going forward is whether patient demand for services will be affected at all by evidence-based guidelines.

What's left unsaid: Patients can take a chance on unnecessary screenings in part because they don't directly pay for them. Insured patients do shell out thousands of dollars in premiums every year, and many would argue that they're paying for services like mammograms with those dollars. But the disconnect between the direct cost of the test and the amount paid for insurance means patients can make decisions about receiving more tests while the direct cost is shifted elsewhere.

Physicians
What they say: Physicians want better evidence about which treatments and screenings work. However, they are genuinely concerned about patient care and don't want to jeopardize patient safety, so if evidence-based guidelines aren't sound, physicians aren't going to follow them.

But there are also concerns about liability if a serious illness or injury sneaks by undiagnosed, and many physicians admit that they order imaging tests defensively. Some doctors are also worried that the toothless guidelines will someday lead to financial restrictions on the care they can provide.

Little-Known Medicare Pay Code Change Will Hurt Specialists

Wed, 18 Nov 2009 17:20:00 GMT

While the theatrics of the reform debate hold the nation in suspense, another dramatic policy change—with potentially tragic ramifications—has crept into next year's Medicare physician pay schedule with astonishingly little fanfare.

But specialty providers who are now becoming aware of the plan say it will have dire consequences for care far into the future, especially for rural communities where specialty doctors are in heavy demand.

"When these doctors find out about this, they are going to go ballistic," says Larry deGhetaldi, MD, administrator of the Palo Alto Medical Foundation, a multi-specialty group practice with 900 physicians in Santa Cruz, CA.

He adds that if it weren't for the complexity and anxiety over health reform, "this would have been the major freak-out issue."

As of Jan. 1, the Centers for Medicare and Medicaid Services plans to eliminate a series of five-digit CPT codes that specialist physicians, such as cardiologists, oncologists, and surgeons, use to bill for medical or surgical consults. These consults occur at the request of a practitioner who wants a specialist's opinion regarding his or her patient.

For example, an internist may want his patient seen by a vascular surgeon. Or a family practitioner may want her patient seen by an endocrinologist or pulmonologist.

Under current CMS rules, the CPT code for consultation calls for reimbursement that is between $20 and $50 higher than for a comparable office visit.

But by eliminating the CPT codes, those specialists will be forced to bill under a different payment code bracket, which covers for a simple office visit.

The rule change could have an impact on some specialists' willingness to be available for specialty referral care, either in the hospital or in their office practices, says Ted Mazer, MD, a San Diego area otolaryngologist.

"The potential impact on already endangered ER call panels should have been considered as well. The devaluation of the consultants' services may adversely impact access in both city and rural settings," Mazer says, especially in areas where there is already a shortage of some specialists.

Consultation services are important and time consuming, Mazer explains.

First, the patient's condition must have added complexity or it wouldn't have needed referral.

Second, the specialist performs an independent physical and often gets a separate history of the patient, spending as much as an hour to set a correct diagnosis and course of care. And third, reimbursement policy requires the specialist physician to return to the referring physician a written report of the findings and course of care in the outpatient setting.

All of that takes time and expertise, argues Mazer, who says the specialists' skill and knowledge should be appropriately compensated.

When this change takes effect, he worries that the confusion in what codes Medicare will accept and delays in payment will result in cash flow problems for specialty physicians as well, he says.

The policy change has come about in part because of a desire on the part of the Obama Administration to increase reimbursement to primary care physicians, who are increasingly in short supply. But such redistribution may tend to worsen the schism between those groups and specialists.

But it also has come about because of overutilization, seen by maps that show many areas of the country use specialty consultations far more than in others, deGhetaldi says.

"Patients in certain parts of the country who undergo a routine hospital admission will have 10 consults," deGhetaldi says. "If they force this new patient code, that will control some of these costs."

Why Do Some Hospitals Successfully Implement EHRs and Others Fail?

Tue, 17 Nov 2009 17:39:00 GMT

There are pieces of advice I hear repeatedly when talking with technology executives about implementing electronic health records and why some organizations are successful whereas others struggle. Phrases like "get physician buy in," "allocate more resources for training," and "spend more time planning on the frontend" come to mind. Unfortunately, the advice doesn't always come with strategies on how accomplish it.

Recently, I spoke with Chuck Podesta, senior vice president and chief information officer for Fletcher Allen Health Care, about its conversion to an EHR from Verona, WI-based Epic Systems. He shared the governance structure that the Burlington, VT-based academic medical center established to implement its EHR, which he credits as one of the key factors to their success.

The organization also spent a good deal of time determining "what that project would look like, the resources needed, and the cost associated with it," says Podesta, adding that some organizations spend a lot of time on the RFP process, but not enough time planning how they want the project to unfold.

Prior to its conversion to the EHR, the medical center had a mishmash of systems, Podesta says. Fletcher Allen was a best of breed shop with boutique systems for finance, radiology, and labs. "We had our own home grown clinical data repository--called Maple--that was viewable on the units and it had some clinical information but not a lot and everything else was paper,” he says.

The 562-licensed-bed medical center went live with the first phase of its EHR conversion this past June, which included all of its inpatient clinical applications including the emergency department. Fletcher Allen is tracking metrics linked to clinicians' adoption of the EHR system.

For its computerized physician order entry system, for example, 95% of orders are currently being placed electronically. "We were at about 90% a week out of the gate and we keep moving forward," says Podesta, noting that the system will always have some telephone orders because "it's hard for a physician who is driving a car to access a computer and enter the order."

So what went right?

Podesta says the medical center had the right number of committees and each committee knew what its role was and, just as important, what its role was not. "It was set up in a way that it wasn't too bureaucratic, but had enough meat to it that people felt if they had issues they had a place to take them and they would be worked on and decided on quickly," he says.

Fletcher Allen established three committees: a patient care operations group that was a multidisciplinary group of nurses and physicians focused on workflows at the unit level, a physician advisory council that was instrumental in keeping the physician side of the project moving forward, and a clinical transformation group.

Do Physicians Have the Time for Quality?

Thu, 12 Nov 2009 19:08:00 GMT

This week's mixed-bag news item comes from a study that found primary care physicians have been spending more time—and not less, as anticipated—with their adult patients compared to a decade ago.

That's good news for patients—and very surprising in light of the reimbursement system that pays primary care physicians proportionately less than other physicians.

However, the corresponding gains made in quality improvement remained sometimes modest, or even flat, for many of those physicians.

Previous studies have suggested that "significant investments of primary care physician time" may be required to deliver high quality care, said researcher Lena Chen, MD, of the University of Michigan Health System in Ann Arbor, in the study that appears this week in the Archives of Internal Medicine.

So Chen and her colleagues went out to find whether "efforts to improve efficiency" might have a detrimental effect on quality of care at the visit level. They started by conducting a retrospective analysis of visits by adults 18 years or older to a nationally representative sample of office based primary care physicians in the U.S.

What they found was that between 1997 and 2005, adult primary care visits in the US increased from 273 million to 338 million annually—or 10% on a per capita basis. At the same time, the mean visit duration increased from 18.0 to 20.8 minutes.

Visit durations increased by 3.4 minutes for general medical examinations and for the three most common primary diagnoses of diabetes mellitus (4.2 minutes), essential hypertension (3.7 minutes), and arthropathies (5.9 minutes). Comparing the early period (1997 2001) with the late period (2002 2005), quality of care appeared to improve for one of three counseling or screening indicators and for four of six medication indicators.

Why the New Public Option is Better for Physicians

Thu, 12 Nov 2009 15:35:00 GMT

Physicians may have dodged a bullet with the House of Representatives' passage of healthcare reform legislation on Saturday. Instead of tying provider payments to Medicare rates, the public insurance option in HR 3962 requires the government to negotiate with physicians, which could have a big impact on the final levels of reimbursement.

Set aside for a moment the debate over whether or not a public option should be included in the first place. Even among proponents of the public option, there has been disagreement for months about how such a program should be structured and, specifically, how it should pay providers.

Some wanted to tie reimbursement levels to Medicare rates, which, as you already know, often don't cover the costs of care and are generally much lower than rates paid by private insurers. The idea was to keep premiums and costs for the plan low by paying providers a little less, but most physicians weren't too keen on the idea of having more of their payer mix affected by the Sustainable Growth Rate formula and annual payment cuts like the pending 21% reduction set to take effect in January. The AMA and some other physician groups lobbied against this method, and early on it looked like the only concession they had earned from the House was a promise to pay 5% higher than Medicare.

But the thing to keep in mind about the healthcare reform process is that most of the debate over healthcare from July until fairly recently has only been committee work. The public option that physicians thought they were getting in August has turned out different from the public option in the final House bill, and it may still change before all is said and done. The Senate still has to pass its own bill, and then the House and Senate versions will be merged into a final piece of legislation.

At this point, I would say the odds are good that if a public insurance option is included in a final bill, it will retain negotiated payment rates. The House was always expected to produce the more "robust" public option, which would then have to be pared down when it came time to merge with a Senate bill that was expected to contain a more watered-down version, if it included a public plan at all. Now that the House is entering into the final stages with a public plan based on negotiated rates, it's unlikely that the Senate will break character and pass some kind of plan that's tied to Medicare.

So physicians have not only avoided one of their worst fears related to reform, but they may also get a little boost. The bill is expected to cover 96% of the population. While some of the people who are currently showing up at the ED without insurance may end up on Medicaid, which pays even lower than Medicare, some may end up using a public insurance option that will now pay closer to rates established by private payers. Uncompensated care should become rare.

Pay-for-Performance Participation Can Be Pricey for Docs

Tue, 10 Nov 2009 13:20:00 GMT

Pay for performance may be the rage, and the future of physician reimbursement—but it doesn't come cheap.

Responding to all those requests for data, proper planning, training, coding, data entry, and modification of electronic systems cost physician practices between $1,000 to $11,100 in implementation costs per doctor, and from about $100 to $4,300 per year per clinician after the program was launched, according to a survey of eight physician practices participating in four quality reporting programs in North Carolina.

"One thing is clear," wrote Jacqueline R. Halladay, MD, the study's author and a UNC researcher. "Participation in quality-reporting programs requires resources that have measurable costs. The costs appear high, especially when compared with the modest reimbursement offered by many programs."

The report added, "To date, the question of whether participation in quality-reporting is worth the time, effort and expense is largely unresolved."

The study was published Monday in the Annals of Family Medicine.

The UNC report found substantial variation in the resources used by four reporting programs. There was a wide variation in the "amount of work shouldered by the quality improvement program staff, the intensity of a program's quality focus, and the time required for quality improvement work beyond data collecting and reporting."

Small practices appeared especially hard hit by the program participation costs, she said.

The researchers examined costs of four incentive programs: Medicare's Physician Quality Reporting Initiative (PQRI); Improving Performance in Practice in North Carolina and Colorado (IPIP); Bridges To Excellence, (BTE), implemented by Blue Cross/Blue Shield of North Carolina; and Community Care of North Carolina (CCNC).

Practices selected included four for-profit practices, three non-profit practices, and one teaching practice and represented variation in size, ownership, specialty, location, and medical record formats.

The major costs included planning meetings, clinician time required to gather and code data, information technology system modification, and staff time to verify the accuracy of the clinicians' coding.

"Despite the enthusiasm for quality improvement, reporting activities have occurred with relatively little regard to the challenges primary care practices face in collecting and reporting requested data," according to the report.

Most Docs Surveyed Claim Less Control Over Healthcare Delivery

Mon, 09 Nov 2009 19:57:00 GMT

Nearly three out of four physicians say they have less control over the way they practice medicine than they did five years ago, according to a new Internet survey from Jackson Healthcare.

The survey of 1,978 physicians in 50 states blamed the perceived loss of control on medical malpractice litigation, and insurance and government interference. However, 85% of the physicians say the threat of medical malpractice litigation is their primary obstacle to practicing medicine as they see fit.

"We found that regardless of a physician’s political affiliation, the respondents attributed the practice of defensive medicine to excessive waste in the healthcare system," said Rick Jackson, chairman/CEO of Jackson Healthcare, an HIT and clinician staffing provider based in Alpharetta, GA.

Jackson found that 62% of physicians disagreed with the American Medical Association's support of healthcare reform, including 46% who say they "strongly disagree." When asked which piece of existing legislation they most support, 44% selected HR 3400, 15% selected HR 3200, 7% selected the Senate Finance Committee bill, and 19% supported none of these plans. Although no piece of existing legislation "very strongly" represented physician views, 92% of respondents said tort reform had to be a primary component of any healthcare legislation..

Physicians also want healthcare reform legislation to include:

Private insurance industry reform, including the elimination of pre-existing condition refusals, the elimination of dropped coverage (except in instances of fraud), and portability (78%)

Allow professional, trade and industry associations, including Chambers of Commerce, to provide healthcare insurance to member groups (67%)

Allow individuals to opt-out of Medicare or their employer-sponsored plan, and provide credits for them to purchase a plan on the individual market (61%)

Create an insurance exchange that provides competition on health insurance plans (54%)

Surgeons Give Six Reasons Why Senate Reform Plan Will Worsen Care

Thu, 05 Nov 2009 13:31:00 GMT

The American College of Surgeons, a group representing 200,000 doctors in 20 surgical specialties, says it will fight health reform as proposed by the Senate Finance Committee, because "it will make an already-flawed system worse" in six ways.

A. Brent Eastman, MD, chairman of the ACS Board of Regents, emphasizes that the doctors are not opposed to health reform per se, and supports changes to provide cost-effective, high-quality care.

But "too many of the provisions that the Senate Finance Committee considered put patient access and quality improvement at risk," says Eastman, who also a trauma surgeon and chief medical officer at Scripps Health in San Diego.

He made the statement yesterday on behalf of 19 other professional societies, including anesthesiology, colon and rectal, endoscopic, gastrointestinal, neurology, obstetrics and gynecology, ophthalmology, orthopaedic, osteopathic, plastic, urology, and vascular surgeons. Their objections were sent in a letter yesterday to Senate Majority Leader Harry Reid.

"This is the first time you're seeing a large group of physicians, surgical organizations stand up" to oppose this, says Christian Shalgian, ACS' director of advocacy and health policy. Though ACS has sent six or seven letters over the last year expressing objections as health reform language began to take shape, "our concerns have been quite frankly ignored."

Eastman stresses that the doctors are not opposed to health reform, and favor the recently released proposals in H.R. 3962, the Affordable Healthcare for America Act, as well as the Sustained Growth Rate formula fix, H.R. 3961.

But the groups are opposed to the Senate proposals because they contain the following six provisions:

1. It would mandate that all physicians participate in Medicare's "seriously flawed," Physician Quality Reporting Initiative, and penalize those who decline. The PQRI program, which was launched for voluntary physician participants in 2006, calls for doctors to submit quality data on how they provided 100 types of care, such as whether appropriate antibiotics were administered prior to surgery.

In exchange for volunteering the information, the doctors were to receive bonuses in their reimbursement.

However, after CMS told doctors to send in their quality data, and after doctors faithfully followed the instructions, CMS "acknowledged that the instructions were wrong; that they had made mistakes, and that they would fix the problem and come back to doctors with a clear set of instructions," Eastman says.

"That was in 2007—we are now almost to 2010—and we still haven't heard from them what that clear set of instructions are supposed to be. And now the Senate want to mandate that we participate in the program?" says Eastman.

He adds, "This doesn't make any sense, and it certainly won't improve quality."

"They would go the whole year submitting their data, but never got the bonus payments," adds Shalgian. "They'd contact CMS, which said the doctor 'didn't participate appropriately, didn't send in the right information or sent it in on the wrong form.'"

Additionally, Eastman and Shalgian, say that participating physicians have received little, if any, of the bonus payments that were promised.

Doc-owned Hospitals: DOJ Settlement Shows Problems with Corporate Hospital Chains

Tue, 03 Nov 2009 20:32:00 GMT

Physician-owned hospitals today launched a media counteroffensive with news that the Department of Justice reached a $27.5 million settlement with for-profit Universal Health Services and its subsidiaries for violations of the anti-kickback and false claims laws at the corporation's hospitals in McAllen, TX.

In a sharply worded press release, the trade group Physicians Hospitals of America said the DOJ settlement "uncovered the real problem—large, corporate hospitals who now owe millions for their illegal contracting schemes."

"Our opposition has attempted to pass the blame to physician-owned hospitals for cost concerns brought to light by a June 2009 article published in The New Yorker," said PHA Executive Director Molly Sandvig. "As the DOJ settlement demonstrates, that is simply not the case. The problem has never been physician ownership. The real problem lies with big corporate hospital chains."

DOJ announced last week that the whistleblower settlement with UHS' McAllen Hospitals LP, d/b/a South Texas Health System, was prompted by violations of the False Claims Act, the Anti-Kickback Statute, and the Stark Statute between 1999 and 2006 by paying illegal compensation to doctors in order to induce them to refer patients to hospitals within the group. DOJ said STHS entered financial relationships with several doctors and induced them to refer patients to STHS hospitals. The payments were disguised through sham contracts, including medical directorships and lease agreements, according to the DOJ.

STHS declined to comment on Wednesday.

Sandvig says corporate hospital lobbyists have successfully inserted in the House and Senate healthcare reform bills language that attacks physician-owned hospitals.

"Congress is about to be railroaded into punishing innocent physicians who have been trying to bring reform to hospitals by the same type of big hospital corporations that were finally caught in McAllen," Sandvig says.

Partnership Tests Value of EMRs

Tue, 03 Nov 2009 17:39:00 GMT

Many Americans are nervous about the security of their personal health information in a digital interoperable healthcare system—and for good reason. It seems like there is a new headline every week about a data breach involving personally identifiable patient information. Healthcare isn't exactly known for being the most advanced when it comes to data security. The industry still has a long way to go when it comes to securing electronic data. Unlike a paper-based health system, criminals don't need to break-in to a physical location to gain access to personal health information in a digital world.

So it's understandable that some people are a bit anxious about allowing their personal health information to be stored and shared in electronic health records and health information exchanges. But it is important for the health industry to demonstrate the value of electronic health records, build trust, and encourage the community-at-large to opt in and allow their information to be exchanged, because managing populations of patients is a key factor to realizing the value of electronic medical records (see "Unlock Value," October 2009).

Managing populations of patients with chronic illnesses, using de-identified data for genomics research, and tracking disease outbreaks are just a few examples of how providers will be able to use information stored in EHRs to control costs and improve quality of care in the future.

If people can see the value of capturing digital health information, they are more likely to take some risk and allow providers access to their personal medical information—especially if the data is de-identified and proper security precautions are taken.

The Centers for Disease Control and Prevention and GE Healthcare's recent announcement that they are partnering to monitor H1N1 and seasonal influenza activity may be just the opportunity needed to generate widespread support of EHRs from the public. Under the agreement, GE Healthcare will submit real-time information on the status of influenza activity from its Medical Quality Improvement Consortium, an electronic health record repository that uses de-identified data and meets HIPAA guidelines.

Participating physicians contribute patient data to the MQIC each day through the normal use of GE's Centricity electronic medical record. Information collected during the patient visit is fed to a data repository where the information is de-identified while still onsite at the provider location. After the data is de-identified, it is automatically transferred to GE's MQIC database every 24 hours.

The MQIC, which includes nearly 14 million patient records, enables the CDC to track clinical symptoms, such as fever, nausea, and chills, as well as variables like pregnancy and patient age, within 24 hours of being documented.

"The speed of which we are doing this can't happen in a paper world," says Mark Dente, MD, chief medical informatics officer for GE Healthcare. Traditionally, the CDC would rely on insurance claims data, which has a much longer lag time, to track diseases.

Dente says three benefits of the system are:

Speed. Data are collected on a 24-hour cycle that can be used to monitor events like H1N1 or a salmonella outbreak.
Standardization. Researchers can query a condition like hypertension and the database will include all variations of that nomenclature like HTN or high blood pressure in the results.
Analytics team. To help identify unique occurrences, GE has a team of statisticians and epidemiologists helping identify any thing unusual so that the CDC can get a baseline as quickly as possible—within hours versus weeks.

The health industry is already treating high volumes of patients who are flooding into doctor offices and emergency departments concerned about H1N1 and the health of their children and loved ones. If this partnership and its use of EMR data to track outbreaks of H1N1 can better prepare regions to treat the needs of its community, it stands to reason that people who have reservations about having their personal health information online may change their view. Of course if the EMR data doesn't really change the response time to an outbreak or prove to be more effective than traditional avenues, the opposite may hold true.

21% Pay Cut May Force Physicians To Stop Seeing Medicare Patients

Mon, 02 Nov 2009 13:19:00 GMT

It's a threat made many times before. Large numbers of doctors will stop accepting new Medicare patients, and may scale back their existing Medicare patient roster, if a 21% Medicare pay cut goes through as scheduled in January.

This time more than ever, physicians say they're serious.

"Access to care and choice of physician for seniors, baby boomers and military families is at serious risk and Congress must fix the payment formula once and for all this year," says J. James Rohack, MD, president of the American Medical Association.

The 21.2% cut is "the largest payment cut since Congress adopted the fatally flawed Medicare physician payment formula," he says.

A remedy is on the way with H.R. 3961, legislation introduced Thursday in the House Ways and Means Committee. It would stop the 2010 payment cut from going through, at an estimated cost of $239 billion.

It would also "replace the physician payment formula (known as the Sustained Growth Rate or SGR) with a more stable system that ends the unrealistic cycle of threats of ever-larger fee cuts followed by short-term patches," according to a Ways and Means statement issued Thursday.

The new formula would:

Remove items such as drugs and laboratory services not paid directly to practitioners from spending targets in Medicare Part B (physician services).
Allow the volume of most services to grow at the rate of the gross domestic product plus 1 percentage point per year.
Allow the volume of primary and preventive care services to grow at gross domestic product plus 2% per year.
Encourage coordinated innovative care through Accountable Care Organizations, which would be responsible for their own growth paths, without regard to reductions or increases that apply elsewhere in the system.

Ted Mazer, MD, a California ear, nose and throat specialist, confirms that doctors will find it difficult to continue seeing Medicare patients, especially taking on new patients. Additionally, all other physician reimbursement from government funds tied to Medicare, such as those paid by CHAMPUS for military dependents, is affected as well.

Already, he says, many physicians are saying goodbye to Medicare and going to "concierge-only" practices, where they accept an annual fee or retainer with a promise of providing enhanced care.

Mazer says the key problem is how the formula treats the calculation for purchasing and administering intravenous drugs for cancer or renal failure patients in their office settings. "The way it is now, doctors who administer these therapies in their offices have to lay out the money to buy these costly drugs and they're not reimbursed that cost. Under the current formula, the cost of those drugs comes under physician services, under Medicare Part B," he says.

Which Patient Gets into the OR First?

Thu, 29 Oct 2009 15:20:00 GMT

When several patients needing urgent or emergent surgery arrive at a hospital simultaneously, who decides which case gets into the OR first? For true emergencies, the decision is generally straightforward, with the patient rushed into the first available room.

But in many other situations, the decision is not as clear: Should the patient with an open fracture go first; should it be the patient with an ectopic pregnancy, or perhaps the patient with an intestinal obstruction? Does the most senior surgeon get the first available OR slot? Should the decision be made on the basis of first-come, first-served? Or maybe the most assertive surgeon gets his or her case in first?

Often the decision falls to the anesthesiologist of the day in the OR. But no matter who makes the decision, the competition between surgeons over this matter, and the daily arguments with anesthesiologists, cause frustrations to both surgeons and anesthesiologists. And at times, patients end up waiting for surgery longer than is clinically optimal.

Ideally, the decision should be based on an objective measure that reflects the clinical needs of the patient and gives surgeons, anesthesiologists, and OR staff a predictable and fair system for prioritizing their cases.

An Innovative Approach
Wellstar Kennestone Hospital, a 600-bed hospital in Marietta, GA, working with Press Ganey, developed an innovative approach to this problem. As part of a significant initiative to improve patient flow through the OR, the surgical services committee—a committee composed of well-respected surgeons and anesthesiologists representing different services—developed criteria for classifying all emergent and urgent cases based on the medical needs of the patient.

The classification system was then used to determine the order in which cases were taken into the OR. It created a system that was fair, predictable and based on clinically-defined criteria. The clinical urgency system was used in conjunction with other patient flow improvement initiatives, including designating separate ORs for these add-on cases.

The surgical services committee decided to use five categories to classify its urgent and emergent cases. Time limits were set for each category, defining the maximum amount of time that should pass between the time a case was posted and when the patient was taken into the OR. Each specialty reviewed its common procedures and placed them into the category into which they would most commonly fall.

The five categories, and their corresponding time limits, were:

A. Acute life and death emergencies (30 - 60 minutes). Examples: Massive bleeding and airway emergencies.
B. Emergent but not immediately life threatening (< 2 hours). Examples: Acute spinal cord compression, bladder rupture, ectopic pregnancy.
C. Urgent cases (< 4 hours). Examples: Asymptomatic foreign body, appendicitis with sepsis/rapid progression, biliary obstruction, open fracture.
D. Semi-urgent (< 8 hours). Examples: Appendicitis, closed reduction of fracture, empyema.
E. Non-urgent cases (< 24 hours). Examples: Facial nerve decompression, femoral neck fractures, mastoidectomy.

Once the categories were developed and accepted by the surgeons, they began to use them to specify the urgency of add-on cases as they posted them. The system works in the following way:

When a surgeon posts a case, he or she classifies its urgency by using one of the five categories based on the needs of the patient. The appropriateness of the classification is never questioned at the time the case is posted but may be reviewed by the committee retrospectively. The order in which add-on urgent/emergent cases are then scheduled into the OR is based on the urgency of the case and the amount of time that has passed since the case was posted. If two cases within the same category arrive close together, they are taken in order of first-come, first-served.

Cutting Costs by Profiling Physicians

Thu, 29 Oct 2009 15:08:00 GMT

Think back to Atul Gawande's influential article about healthcare costs in the New Yorker earlier this year and the debate it sparked about overutilization. The article was forwarded throughout the industry, became mandatory reading at the White House, and may even shape future healthcare policy. All of this from a relatively simple comparison of Medicare costs in two Texas towns.

Kind of broad brush, isn't it? There are a lot of good physicians who don't overutilize—even in McAllen, TX, where Medicare spends $15,000 per enrollee, almost twice the national average. And there are plenty of physicians who overutilize in regions that look below average on paper, at least according to the Dartmouth Atlas and other studies that measure healthcare spending geographically.

The problem is that policymakers are trying to address how physicians use resources, yet most of the data that drives policy decisions and healthcare research measures how regions use resources.

CMS is trying to develop more granular data at the physician level. The Government Accountability Office, MedPAC, and the Congressional Budget Office have all recommended in recent years that CMS profile physician resource use and provide feedback as a step toward improving Medicare efficiency.

But how?

MedPAC has explored episode-based profiling, which measures the resources used for treating a particular episode of care or a specific illness. But we're still locked into a fee-for-service system, so other options have to be considered.

This week, the GAO released a report evaluating per capita profiling, a method that measures a patient's resource use over a fixed period of time and connects that resource use to physicians.

The report focused on cardiologists, radiologists, internists, and orthopedic surgeons in Miami, Phoenix, Pittsburgh, and Sacramento, and risk adjusted data to account for patients' health conditions.

In each of the four metropolitan areas, physicians were fairly stable in their resource use, even when their patients' resource use varied. And patients seen by "high-resource use" physicians generally were heavier users of institutional services (such as hospital services) than those seen by lower resource use physicians.

House Passes Red Flag Exemption for Small Practices

Mon, 26 Oct 2009 14:38:00 GMT

The House of Representatives unanimously passed a bill Tuesday, October 22, that would exempt a healthcare practice with 20 or fewer employees from the FTC's identity theft Red Flags Rule requirement.

The bill moves onto the Senate.

The Red Flags Rule, which will be enforced starting November 1, 2009, requires healthcare entities considered to be "creditors" to implement an identity theft prevention program.

Further, the bill passed by the House last week, which was filed by John Herbert Adler (D-NJ), Paul Collins Broun, Jr. (R-GA), and Mike Simpson (R-ID), lets off the hook an entity that:

Knows all of its customers or clients individually

Only performs services in or around the residences of its customers

Has not experienced incidents of identity theft and identity theft is rare for businesses of that type

The FTC would determine if a business meets these criteria.

AMA Launches Web-based Flu Assessment Program

Thu, 22 Oct 2009 18:15:00 GMT

The American Medical Association today launched a new Web-based program to improve patients' and physicians' communication and coordination of care for seasonal flu and the H1N1 virus. AMA is touting the Web site, AMAfluhelp.org, as the nation's first comprehensive Web-based patient flu health-assessment program.

"This resource allows patients to assess their symptoms and determine when to seek care for themselves or their loved ones," said Mary Anne McCaffree, MD, an AMA board member. "To prevent the spread of influenza, this site also helps determine when it is safe for those who have been sick to return to work or school."

The Web site asks patients questions to determine the severity of their flu symptoms based upon the latest CDC guidelines. Patients can share their information with their physician, as well as family members and loved ones. AMAfluhelp.org also provides a set of online tools to help physicians monitor their patients' symptoms, facilitate care and treatment decisions, and efficiently manage their practices' patient flow.

AMAfluhelp.org can help patients assess their own flu symptoms, or those of a child or loved one, and offer guidance on whether they should seek care. There is also a choice for pregnant women to evaluate their need for a flu vaccination and for all patients to monitor any post-vaccine related symptoms. AMAfluhelp.org can also generate a doctor's note when it is safe to return to work or school.

The Web site is in collaboration with the Flu Information & Care System, which includes: AllOne Health, BlueCross NEPA, CVS Caremark, EMSC, HealthyCircles, HERAE, Merck, MedImpact, Microsoft, Minute Clinic, Schumacher Group, Staywell/Krames, Team Health, and WorldDoc.

The SGR Lives, For Now

Thu, 22 Oct 2009 16:16:00 GMT

The future of physician reimbursement is now officially tied to the outcome of healthcare reform efforts. Yesterday, the Senate failed to garner enough votes to overcome the filibuster of S.1776, known as the Medicare Physician Fairness Act, which would have eliminated the 21% Medicare physician reimbursement cut set to take effect in 2010.

Unless additional legislation is introduced, the only remaining hope for eliminating the cuts mandated by the Sustainable Growth Rate formula is in HR 3200, the House healthcare reform bill.

We've been through this song and dance routine many times before, and for several years Congress has intervened at the last minute to prevent Medicare cuts that would have slashed physician pay and led many providers to stop accepting Medicare patients. Only this time the cut is much larger and the Congressional intervention is happening in the middle of a heated ideological debate about broader healthcare reform.

Which is probably why Senator Bob Corker (R-TN) called the legislation "a ponzi scheme" and asked his Senate colleagues to revolt "against this most sinister act."

Corker and other Republicans argue that Democrats are trying to handle the physician payment fix separate from healthcare reform legislation in order to deceptively keep reform budget-neutral. There's a point to that. Eliminating doctor pay cuts adds nearly $247 billion to the deficit over 10 years, and Democrats don't want that to count against them.

But in many ways it is a separate issue. Even if Congress wasn't debating reform, even if the current reform bills were withdrawn from consideration tomorrow, physicians would still be facing a 21% reimbursement cut and Congress would still be forced to debate the consequences of letting the cut take effect.

The physician fee schedule is like that frequent flyer patient that keeps showing up on the operating table; let's call him Steve. Steve smokes. He's obese. He doesn't exercise or utilize preventive care, and each year the poor health catches up with him when he's rushed to the hospital after a heart attack for a major, life-saving intervention.

Thanks to last-minute action, Steve hasn't died yet, but he hasn't gotten noticeably healthier, either. Each year he's back again, only a little worse for wear. Those Medicare cuts are growing exponentially—last year's would have been 10.6%, and the ones before that were only single digits. By 2016, they're scheduled to add up to 40%.

The Medicare Physician Fairness Act would have gone much further than previous efforts. Instead of a one-time intervention—a Band-Aid, as it has often been called—it would have essentially reset the payment updates at zero and repealed the SGR formula altogether. The AMA, AARP, and other groups understandably campaigned intensely to make this happen.

In our analogy, this bill would have given Steve a coronary stent, blood pressure medication, and set up an appointment with a primary care doctor to ensure that he doesn't end up in the emergency room for a long while.

But S. 1776 didn't offer a replacement for the SGR methodology, so it would have prevented annual emergencies but stopped short of a sustainable fix. In Steve's case, any treatment is limited in its effectiveness if he continues his current lifestyle. If he doesn't lose weight and stop smoking, he's not getting at the underlying drivers of his health problems.

Five Lessons on How to Get Physicians to Adopt CPOE

Tue, 20 Oct 2009 19:08:00 GMT

I often read or hear about "physician buy-in"—as I'm sure most of you do too—as the key component to successfully implementing many IT projects, including computerized physician order entry. While I agree that physicians need to join the effort for CPOE to be successful, I also think there is a lot more behind the successful implementations—like dogged persistence.

I recently spoke with Cynthia D. Burton, RN, who is the chief nursing officer and CPOE champion, if you will, at Rockcastle Regional Hospital and Respiratory Care Center in Mt. Vernon, KY, about her organization's switch to electronic health records and CPOE. Rockcastle, which had a completely paper clinical record, opted for a big bang approach in its switch to an EHR and went live with its CPOE system in November 2007. Today, the 26-bed acute-care facility has 100% of its orders entered through its CPOE system and 75% of those orders are entered directly by physicians. Yet, if given the choice today, there are still a handful of physicians who would jump at the chance to stop placing orders electronically, says Burton.

"Do they like it? No. Would they go back in a minute? Yes," she says, clarifying that that sentiment is solely for CPOE. The physicians would not want to go back to paper after using the electronic health record system and being able to access lab results with the click of a mouse, she says.

So how did Rockcastle get its physicians on board and more importantly using CPOE?

"We were going to do CPOE from the very beginning, so every time we talked about the record we constantly talked about how we are going to do this," Burton says. "We continued to say we could do it. I think it was just that constant positive discussion about it."

Here are five lessons Burton learned along the way.

Lesson 1: Sell the advantages. "We kept talking in a positive manner," says Burton, while acknowledging that, yes, it will be hard. Burton played up the fact that physicians would no longer have to look through paper charts for lab results, for example.

Lesson 2. Physicians don't like to train in groups. Rockcastle, which has about 25 physicians, including 12 primary-care doctors who are there most of the time, had a group training session with the physicians to show what the system would look like. Then the system arranged training sessions with no more than two physicians at a time. "They were more likely to ask questions or admit weaknesses when alone rather than in groups," says Burton.

Lesson 3. Provide support—especially early on in the process. Rockcastle identified three nurse champions to help physicians initially and that number grew to four. They were involved in physician training sessions so they could answer questions and assess the doctor's computer skills. "The nurses' job was to smooth the way for the physicians," says Burton. "Pick up questions and get them the answers that they needed." When the system went live the nurses were there around the clock for two weeks. For the first few days, if a doctor was using the system, there was a nurse at their elbow, says Burton. "When you start the process you have to have plenty of resources, so when physicians get on the computer there is someone right there to answer questions because it is frustrating if they can't get the assistance they need."

AMA President: Physician Fee Schedule Obsolete

Tue, 20 Oct 2009 18:47:00 GMT

American Medical Association President J. James Rohack, MD, says budget neutrality in the healthcare reform debate should not derail the push to abolish what he says is an obsolete Medicare physician fee schedule that will carve out up to $245 billion in payment reductions for physicians.

"From a practical standpoint, this problem predates any discussion of health system reform by this current president," Rohack tells HealthLeaders Media. "This problem was adopted in 1997. The first problems in cuts started in 2001. This is a leftover problem that should be standing on its own and should be fixed on its own and not be considered part of a new package that a new president is considering."

Rohack is in Washington this week to lobby the Senate in support of the Medicare Physician Fairness Act of 2009, or S. 1776.

Budgetary rules require Congress to offset any increased spending for healthcare reform under a sustainable growth rate formula that was implemented in 1997. S. 1776, sponsored by Sen. Debbie Stabenow, D-MI, would reset the SGR formula to zero and eliminate what is estimated to be up to $245 billion debt that has accumulated during the past six years as a result of Congress' annual fixes to ensure physician payments were not reduced.

The AMA, the American Academy of Family Physicians, and other physicians' organizations have banded together in support of the bill.

Rohack says the new emphasis on cost-saving, patient-centered, preventative care makes the SGR formula obsolete. Abolishing the formula, he says, would allow Congress to develop a new payment system that rewards efforts to treat and control chronic diseases, and reduce hospitalization. "This formula is designed to make cuts as volumes go up. It's an old formula that doesn't reflect what 21st medicine is and will become even more in the future," he says.

Physician Groups Back Medicare Payment Reform Bill

Thu, 15 Oct 2009 21:01:00 GMT

Physicians' organizations are mounting a concerted campaign to roust support for a newly introduced bill in the U.S. Senate that would do away with the Medicare physician fee schedule under the sustainable growth rate formula.

"This legislation is going to move very quickly, so we need to act now to ensure that it passes," says Lori Heim, MD, president of the American Academy of Family Physicians. "Senators need to hear from physicians today on the importance of voting in favor of each of these procedural votes. Healthcare reform really does require that we address the flawed current formula for Medicare payments. This would give us the basis for that fix."

Budgetary rules require Congress to offset any increased spending for healthcare reform. The so-called Medicare Physician Fairness Act of 2009, or S. 1776 would reset the SGR formula to zero and eliminate the $245 billion debt that has accumulated during the past six years as a result of Congress' annual fixes to ensure physician payments were not reduced. AAFP says resetting the SGR debt will allow Congress to establish a new payment system based on quality of care rather than the quantity of procedures or services.

"S. 1776 would mean that Congress can finally recognize that the annual overriding of the reductions that the badly designed (SGR) formula generates is simply postponing the needed replacement of the payment formula," AAFP wrote in a letter to members. "It is critically important for Congress to face this responsibility and pass S. 1776 this week."

Before the bill—sponsored by Sen. Debbie Stabenow, D-MI—can reach the Senate floor, it must have at least 60 votes on each of three procedural votes, with the first vote expected on Monday.

"We need 60 'aye' votes on each of these steps so the full Senate can take up this bill. Without this legislation, we won't have a permanent payment fix, and we're facing a 21% cut in Medicare payment at the end of the year," Heim says.

A permanent repeal provision is already included in the House health reform bill.