Life Sciences

Medicare & Reimbursement Advisor Weekly, March 25th, 2009

Medicare & Reimbursement Advisor Weekly, March 25, 2009



No longer influencers, nurses and PAs elevate in managed markets strategy

As nurse practitioners (NP) and physician assistants (PA) take on different roles in patient care, and even open private practices, managed markets needs to account for the emerging role these mid-level providers and prescribers play in therapeutic decisions.

One emerging trend is an increase in private practice NPs and PAs who have gained privileges at their local hospitals, so they can follow patients through the care continuum.

As the primary care physician shortage worsens, and NPs step up to supplement this shortage, hospitals will have little choice but to grant privileges to NPs, according to 78% of 1,311 hospitals polled last week by MRAW’s publisher, HCPro, Inc.

Keep in mind that despite the overcrowding in hospitals, there’s the opinion among many patients, particularly in rural America, that hospitals are a last resort.

Jennifer Scott, an advanced RN practitioner, who works in a rural general practice in Florida, says, “Some of my patients refuse to go into a hospital setting until it is almost too late, because I wouldn’t be the one taking care of them. They trust me almost to the detriment of their own health.”



LTC regulation could have ripple effect

For those of you with products to treat pain and other conditions such as depression (common in the LTC population), a new Medicare LTC regulation to take effect in 2010 will likely increase the diagnosis of pain and increase opportunities for appropriate utilization of branded agents with an above-average side effect profile. Even if LTC is not specifically important to your job, the regulation and the document that results from it may become evidence for the government to use in determining the most therapeutic and cost-effective ways to treat the LTC elderly.

Specifically, the regulation (called MDS 3.0), will mandate nursing homes to ask residents and patients the following questions:

  • Have you had pain or hurting at any time in the past seven days?
  • How much of the time have you experienced pain or hurting over the past days?
  • Over the past seven days, has pain made it hard for you to sleep at night?
  • Over the past seven days, have you limited your day-to-day activities because of pain?

The MDS 3.0 also instructs the assessor to ask the resident to rate his or her worst pain in the past seven days with a numeric rating or a verbal descriptor (i.e., “mild,” “moderate,” “severe,” “very severe,” “horrible”).

This represents a shift from the current MDS 2.0 rules, which rely on staff assessment and observations of whether a resident experiences pain during the past seven days to code pain. MDS 2.0 instructs staff to ask the resident whether he or she experiences pain, but the coding did not reflect what the resident said. Now, it’s the resident’s interpretation of pain, not staff members’ interpretation.

In addition, under a different section of the MDS 3.0, nursing home staff members must interview residents about their mood using a nine-item Patient Health Questionnaire (PHQ-9).

Interviewers must ask the resident whether he or she has been bothered by any of the following problems over the previous two-week period:

  • Having little interest or pleasure in doing things
  • Feeling down, depressed, or hopeless
  • Having trouble falling or staying asleep, or sleeping too much

For residents who cannot be interviewed, the new assessment uses a staff PHQ-9 observational version, which instructs the assessor to ask other staff members whether the resident had any of the nine listed problems or behaviors during the past two weeks.

About 70% of nursing home staff members who participated in MDS 3.0 testing found the PHQ-9 easy to use, according to the 2008 RAND Corporation Report on MDS 3.0 testing and validation. The PHQ-9 is also a more reliable and valid method of detecting signs or symptoms of depression than measures used under the MDS 2.0, according to the report.

Nursing homes will be required to train their staff on these changes. The greatest training need is education for certified nurse assistants about the assessment and recognition of various diseases common in the LTC population.



Survey snapshot

Community practices have different experience with medication list rules

Forty-eight percent of 1,100 hospitals said they are not yet fully complying with the new Joint Commission rules requiring hospitals to give a list of medications the patients took (at home and during their hospital stay) to the patient’s primary care physician. On the flip side, in a similar poll of 1,100 physician practices, 82% said they have not noticed an increase in medication lists being supplied by hospitals that cared for their patients during a stay in 2009.

Note: The polls were electronically disseminated March 16 to subscribers of HCPro’s Case Management Monthly for acute care hospitals and PhysicianLeadersDaily subscribers, who work in community physician offices.



Numbers support hospitalist outreach, increased role in managing patients

What’s the power of the script trail, and where does it lead?

It’s a question that many of you have asked, the thinking behind it being that many scripts begin in a hospital and have a kind of trickle down effect. Physicians and nurses in nursing homes, community practices, and home health may keep patients on the same drugs as the patient took in the hospital, at least for a transition period.

As we explore this question further in follow-up issues, I thought it was at least worth introducing it as a tie-in to more news this week about the increasing role and influence of hospitalists in the United States.

According to a study by the Central Utah Clinic Cardiac Hospitalist Service in Provo, hospitalists improve patient outcomes, quality, and cost reduction. The study, “A Systematic Review of Outcomes and Quality Measures in Adult Patients Cared for by Hospitalists vs. Nonhospitalists,” published in the March Mayo Clinic Proceedings, is significant perhaps to your strategies, because of the rise of hospitalists in the United States.

Researchers at the University of Texas Medical Center’s Department of Internal Medicine in Houston conducted a study of 120,226 general internists in 5,800 hospitals in the United States from 1995 to 2006, and discovered that the number of hospitalists more than tripled in the past decade from 5.9% in 1995 to 19.0% in 2006 (New England Journal of Medicine, March 12).

The researchers defined “hospitalists” as general internists, who derive 90% or more of their Medicare claims for evaluation and management (E/M) services.

In addition, the odds of a patient receiving care from a hospitalist also soared—29% each year from 1997 through 2006. The number of Medicare claims for inpatient E/M services attributed to hospitalists also rose from 9.1% to 37.1%.

In the Central Utah Clinic study, researchers found the following:

  • All reports generally indicated shorter length of stay and lower costs
  • Three reports indicated improved patient outcomes in orthopedic surgery cases, in which hospitalists consulted or co-managed the cases
  • Three reports indicated quality improvement in pneumonia patients
  • Two reports indicated improved heart failure management

To conduct market research of hospitalists, contact Editor Bryan Cote at or call 860/232-6377.

Editor’s note: An article and post on the HCPro “Hospitalist Blog” was included in this story.



Seeking younger, healthier patients

Blue Cross Blue Shield (BCBS) of Michigan is offering commissions of up to 20% to insurance agents who enroll consumers “with no major ongoing health conditions” in a new line of individual insurance plans. Agents who sell policies to high-risk consumers earn a commission of only 1% to 2%.

The insurer’s aim is to bring in younger and healthier members to balance the costs of covering sicker customers and to compensate insurance agents similar to other private insurers, according to BCBS.

MA cuts would shift costs to beneficiaries

Proposed Medicare Advantage (MA) cuts and subsequent premium increases could force millions of seniors into traditional Medicare plans without care coordination, and would shift more costs onto beneficiaries, according to a Blue Cross Blue Shield Association (BCBSA) official.

Alissa Fox, senior vice president in the office of policy and representation at BCBSA, which covers 1.6 million MA enrollees in 42 states, the District of Columbia, and Puerto Rico, said the Obama administration’s proposed 5% MA payment cuts to private insurers could increase beneficiary premiums by $50–$80 per month, which will force many, particularly low-income seniors, into traditional Medicare without supplemental coverage. A $50–$80 premium increase would happen if insurers passed the full payment cuts onto members, although they could also combine a smaller premium increase with service reductions, said Fox during a press conference on Monday.

Rather than across-the-board MA cuts, Fox said CMS should review how it pays for services, improve quality through pay-for-performance programs, and target insurers that are upcoding as a way to make more money.

“We think that there are ways to reform the program. We think it should be made more efficient. We think it should be rewarded for demonstration quality,” said Fox. CMS must finalize rates by April 6.



Top stories

Here’s a list of the eight most viewed and e-mailed stories from the 120,000 registered users on for the week of March 23. Simply click the link to track down the story.

1. Nevada medical board may add details to doctors’ records on Web

2. Blumenthal spearheads health IT reform

3. Going abroad to find affordable healthcare

4. Blue Cross Official: Medicare Advantage Cuts Will Increase Premiums, Force Millions Out of Program

5. Stimulus Dollars Go to Medicaid, Health Clinics

6. Cleveland Clinic forum examines solutions to health insurance gap

7. Health clinics in danger of needing life support

8. Pennsylvania lawmaker’s post to Blue Cross board questioned