Why one-third of hospitals will close by 2020
Why one-third of hospitals will close by 2020
by David Houle and Jonathan Fleece
For centuries, hospitals have served as a cornerstone to the U.S. health care system. During various touch points in life, Americans connect with a hospital during their most intimate and extraordinary circumstances. Most Americans are born in hospitals. Hospitals provide care after serious injuries and during episodes of severe sickness or disease. Hospitals are predominately where our loved ones go to die. Across the nation, hospitals have become embedded into the sacred fabric of communities.
According to the American Hospital Association, in 2011 approximately 5,754 registered hospitals existed in the U.S., housing 942,000 hospital beds along with 36,915,331 admissions. More than 1 in 10 Americans were admitted to a hospital last year.
Hospitals make a substantial imprint on local economies. In many communities, hospitals represent one of the largest employers and economic drivers. Of the total annual American health care dollars spent, hospitals are responsible for more than $750 billion.
Despite a history of strength and stature in America, the hospital institution is in the midst of massive and disruptive change. Such change will be so transformational that by 2020 one in three hospitals will close or reorganize into an entirely different type of health care service provider. Several significant forces and factors are driving this inevitable and historical shift.
First, America must bring down its crippling health care costs. The average American worker costs their employer $12,000 annually for health care benefits and this figure is increasing more than 10 percent every year. U.S. businesses cannot compete in a globally competitive market place at this level of spending. Federal and state budgets are getting crushed by the costs of health care entitlement programs, such as Medicare and Medicaid. Given this cost problem, hospitals are vulnerable as they are generally regarded as the most expensive part of the delivery system for health care in America.
Second, statistically speaking hospitals are just about the most dangerous places to be in the United States. Three times as many people die every year due to medical errors in hospitals as die on our highways — 100,000 deaths compared to 34,000. The Journal of the American Medical Association reports that nearly 100,000 people die annually in hospitals from medical errors. Of this group, 80,000 die from hospital acquired infections, many of which can be prevented. Given the above number of admissions that means that 1 out of every 370 people admitted to a hospital dies due to medical errors. So hospitals are very dangerous places.
It would take about 200 747 airplanes to crash annually to equal 100,000 preventable deaths. Imagine the American outcry if one 747 crashed every day for 200 consecutive days in the U.S. The airlines would stand before the nation and the world in disgrace. Currently in our non-transparent health care delivery system, Americans have no way of knowing which hospitals are the most dangerous. We simply take uninformed chances with our lives at stake.
Third, hospital customer care is abysmal. Recent studies reveal that the average wait time in American hospital emergency rooms is approximately 4 hours. Name one other business where Americans would tolerate this low level of value and service.
Fourth, health care reform will make connectivity, electronic medical records, and transparency commonplace in health care. This means that in several years, and certainly before 2020, any American considering a hospital stay will simply go on-line to compare hospitals relative to infection rates, degrees of surgical success, and many other metrics. Isn’t this what we do in America, comparison shop? Our health is our greatest and most important asset. Would we not want to compare performance relative to any health and medical care the way we compare roofers or carpet installers? Inevitably when we are able to do this, hospitals will be driven by quality, service, and cost — all of which will be necessary to compete.
What hospitals are about to enter is the place Americans, particularly conservative Americans cherish: the open competitive market. We know what happens in this environment. There are winners and losers.
A third of hospitals now in existence in the United States will not cross the 2020 finish line as winners.
David Houle is a futurist, advisor and speaker and Jonathan Fleece is a health care attorney, advisor, and speaker. They are the authors of The New Health Age: The Future of Health Care in America.
From KevinMD.com
Navigating the National Public Policy on Prescription Opioids
Navigating the National Public Policy on Prescription Opioids
by Debra Hughes
Medical societies such as the American Academy of Pain Medicine (AAPM) should be involved in any public policy discussions on prescription opioids in order for a reasonable balance to exist between the need for pain management and the need to avoid addiction to and overdose from these agents, said Keith N. Humphreys, PhD, in a plenary presentation during the 2012 AAPM Annual Meeting.
“It is in the public interest and in your interest to be actively involved with the development and implementation of these policies,” he told AAPM meeting attendees.
The number of prescriptions written for opioids have increased from 76 million in 1976 to 210 million in 2010. Deaths from drug overdoses have more than tripled in the U.S. since 1990, from 4 to 12 per 100,000 population, a death rate higher than the heroin and crack epidemics combined, said Dr. Humphreys, of the Veterans Administration and Stanford University, Stanford, CA. These statistics create a “basic tension between maximizing pain relief and minimizing pain addiction,” he said.
To ensure opioids can be made available without increasing addiction, he urged pain-medicine specialists to embrace five emerging public policies, codes of practice, and cultural norms:
1. Prescription monitoring programs (PMPs).
2. Locking doctor-shoppers into a single prescriber.
3. Making prescription “recycling” a cultural norm.
4. Making abuse-resistant medication approval easier.
5. Changing opioid-related medical practice.
1. Prescription monitoring programs (PMPs)
Previously, PMP systems were slow, hard to use, and rarely accessed; however, coverage, utilization, and technological sophistication are improving, and the majority of states now have operational programs. Although PMPs are “resisted and resented by many professionals, they are inevitable,” Dr. Humphreys said, and the more prescribers participate, the better the programs will work.
Challenges to PMP use include ease of access, the need for prescribers who live on state lines to access more than one state’s system, and the quality of the data. For example, a patient may have received three prescriptions from three different prescribers over three weeks, which a PMP may flag as “doctor shopping,” but the physicians may all work in the same practice and the opioids legitimately prescribed.
2. Locking doctor-shoppers into a single prescriber
Doctor shopping is common in much of the U.S., Dr. Humphreys said, and public and private payers can lock such individuals into a single provider to help prevent overdoses and deaths. In 2008, Hall et al. reported inJAMA that more than once weekly, a West Virginian died of a drug overdose while holding prescriptions from five or more providers.
Medical professionals have the credibility to ask state Medicaid programs and private insurers to start lock-in programs, which “protect you and your patients,” he said, and pain-medicine professionals have the expertise to advise payers what the standards should be.
3. Making prescription “recycling” a cultural norm
Pointing out that the most common source of misused opioids is friends and family, Dr. Humphreys added that leftover medication is found in many homes in general and even more so in particular clinical situations, such as hospice care. Prescription take-back days and recycling programs can help drain off the reserve of abusable medication.
He said physicians have the credibility with patients to explain the need to get rid of unused medications and, as a clinical practice, protect family members such as “curious or entrepreneurial teenagers” from procuring opioids. In addition, pain-medicine specialists “have the stature to encourage elected officials and health authorities to facilitate take-back days.”
Dr. Humphreys provided one example: A sheriff’s office in a small town in Arkansas (population: 20,000) held a take-back day and, in four hours, collected 25,000 pills. For those for whom opioids represent a significant expense, however, the likelihood is greater that they will share any unused medications with family and friends.
4. Making abuse-resistant medication approval easier
Developing a new medication and getting it approved costs hundreds of million of dollars. Since abuse-resistant medications are treated as new applications, “drug developers thus face a massive disincentive not to work on abuse-resistant drugs,” he said.
However, the U.S. Food and Drug Administration can always use input on the importance of abuse-resistant medications and, “the more informed any new regulation is, the more pain providers and their patients will benefit.”
5. Changing opioid-related medical practice
Educating patients and fellow providers that prescribing opioids may not be the only response to pain and breaking the “30-day” prescribing habit for opioids are just two ways in which opioid-related medical practice can be changed.
Others include “communicating to patients that sharing opioids is dangerous and illegal, learning how to recognize addiction, and evaluating methods of preventing iatrogenic addiction,” Dr. Humphreys said. One example he provided is whether perioperative gabapentin can reduce the risk of iatrogenic addiction after surgery.
Creating a culture of learning and monitoring around opioid prescribing is one way to navigate the Scylla and Charybdis between treating pain while preventing addiction, he concluded.
From Monthly Prescribing Reference
Posted: 2/27/2012
Smartphones – Magnifying Glasses of the 21st Century
Smartphones and Other Gadgets Help Low Vision
by Laird Harrison
As the population ages, more and more people are turning up in doctors’ offices with low vision, and new gadgets and rehabilitation techniques are becoming available to help improve their quality of life.
The American Academy of Ophthalmology (AAO) is working to educate medical practitioners — including ophthalmologists — that more than many realize can be done to help patients with low vision, said Lylas G. Mogk, MD, an AAO clinical correspondent.
Low vision — a loss of eyesight that cannot be corrected or treated and makes daily tasks more difficult — is becoming more common as more people have such diseases as macular degeneration, glaucoma, and diabetic retinopathy, Dr. Mogk told Medscape Medical News.
“What people often hear from a physician is that there is nothing more that can be done,” said Dr. Mogk, director for vision rehabilitation and research at the Henry Ford Health System in Detroit, Michigan. “There may be nothing more that can be done about the retina but there is a lot that can be done to help the patient function.”
Instead of focusing only on medical treatments, physicians should direct patients to rehabilitation programs, she said. In these programs specialists carefully evaluate patients to determine exactly what they can see and what they can’t.
They then assign the patients to work with occupational therapists who can teach techniques and recommend tools to get around the problem.
Among the hottest new gadgets are applications available for smartphones and other portable devices, said John Kitchens, MD, a partner at Retina Associates of Kentucky in Lexington.
Perhaps the most useful program uses the camera in the device to magnify whatever is on its screen, in combination with the device’s external light to improve contrast, said Dr. Kitchens. One such program is iRead, which is available for iPhones and Android phones for free from the iTunes store. It was developed by Richard G. Davis, MD, an ophthalmologist in Long Island, New York.
Patients with macular degeneration can learn to use such magnification devices to make use of their peripheral vision. Although peripheral vision is not damaged by the condition, it is naturally less clear than central vision.
These products are helpful especially for quick tasks, such as reading the price tag on an item on a store shelf or reading a restaurant menu.
And e-book readers and tablets such as the Kindle and iPad can also magnify text, making it possible for people with mild low vision to read books.
However, Dr. Mogk pointed out that there are still many patients for whom these devices don’t offer enough magnification to make actual reading possible. Or, if they do offer enough magnification, the screen is too small to accommodate more than a snippet of highly enlarged text.
Patients with more severe vision loss can use closed-circuit television (CCTV) devices. These come in 3 different forms. Portable devices are helpful for reading notes at a meeting but are still not adequate for reading at home because the screen is too small.
The second device is a camera that reads and magnifies onto a 17- to 24-inch screen, similar to a television screen. The patient holds the text to be magnified under the camera.
The third type of CCTV device is a camera similar in design to a computer mouse that the patient rolls over the text. The image is projected onto a television.
Other helpful gadgets include:
- Cutting boards colored white on one side and dark on the other side, allowing the patient to choose a side depending on the color of the food to be cut, ensuring high contrast;
- Appliances with large buttons;
- Portable LED lights;
- High-contrast bank checks;
- Simple-to-operate compact disc players to play audio books; and
- Voice recognition programs for telephones and computers, such as Siri, the program introduced with the latest model of the iPhone.
“Siri is fantastic for patients with low vision,” Dr. Kitchens told Medscape Medical News. “It not only transcribes your voice to text, but it will read back what you just created.”
Another smartphone application addresses the problem from a different angle, said Dr. Kitchens. SightBook by DigiSight Technologies allows the patient to test his or her own vision and report the results back to the physician.
This can help patients catch a change before it leads to serious damage. “Some patients will pick up on a problem readily, but others may not notice a change in vision, especially if it’s only in one eye,” said Dr. Kitchens.
The development of such technology has proved a real boon for patients with low vision, said Dr. Kitchens. “And it’s only going to get better.”
The AAO lists resources for low vision rehabilitation on its Web site as part of an initiative called SmartSight.
From Medscape Medical News
http://www.medscape.com/viewarticle/759610?sssdmh=dm1.764049&src=nldne
Posted: 3/2/2012
Presidential Contenders Stand on Healthcare
Where the Presidential Contenders Stand on Healthcare: Other Departures from the ACA
by Wayne J. Guglielmo, MA
Introduction
While jobs and the economy remain the top issues for American voters, healthcare continues to arouse widespread — and often fierce — partisan debate, both on the campaign trail and off.
At the center of this debate is the Affordable Care Act (ACA), the 2010 Obama-led overhaul of the nation’s health system. This month, the Supreme Court will begin to hear challenges to the law’s most controversial provisions, including the mandate requiring most US citizens and legal residents to have health insurance or incur a fine.
A recent Gallup Poll shows that Americans are equally divided over the question of whether they favor or oppose “a Republican president’s repealing the 2010 healthcare law if elected this November.” According to Gallup, 47% are in favor and 44% are opposed.
Out on the Campaign Trail
No such split exists, though, on the GOP campaign trail. The candidates have made the repeal of ObamaCare, as they derisively term it, healthcare priority number one.
Co-frontrunner Mitt Romney, for instance, has vowed on day 1 of his first term to “issue an executive order that paves the way for the federal government to issue ObamaCare waivers to all 50 states.” After this — and assuming the Supreme Court doesn’t do his work for him — he’ll coordinate “with Congress to repeal the full legislation as quickly as possible.”
Romney’s main challenger, Rick Santorum, is equally adamant about repealing ObamaCare. But on the campaign trail and in debates, the former 2-term Pennsylvania senator has also taken aim at his GOP opponent’s healthcare record while governor of Massachusetts from 2003 to 2007.
With its individual mandate and other features, the 2006 Massachusetts Health Plan, Santorum argues, essentially formed the blueprint for the ACA. Remaining GOP hopefuls Newt Gingrich and Ron Paul have hurled very similar accusations at Romney.
Romney has sought to deflect these charges by drawing a sharp distinction between state and federal action on healthcare: The Massachusetts plan was right for the Bay State, he insists, but it should not have served as a template for the nation. Instead, he has called for a restoration of state leadership: “In place of ObamaCare,” his Website advertises, “Mitt will pursue policies that give each state the power to craft a healthcare reform plan that is best for its own citizens.” And what role does the federal government play? It helps “markets work by creating a level playing field for competition” — and then gets out of the way.
Singing From the Same Hymnal
In this, Romney is not only consistent with Republican orthodoxy on healthcare but also aligned with the current thinking of his fellow GOP contenders. Each would replace what is seen as a meddlesome top-down, Washington-run system with one that centers on the patient.
Whereas the ACA sets out a larger government role with the individual mandate, state-run insurance exchanges, and expansions in Medicaid, among other things, GOP candidates seek to rein in this role and place more decision-making and purchasing power in the hands of patients.
They would do this by variously strengthening both the use and power of a number of longstanding consumer-driven tools: health savings accounts coupled with high-deductible plans, healthcare tax credits and deductions, individual and small business purchasing pools, and interstate insurance markets.
At least 3 of the candidates — Romney, Santorum, and Gingrich — would also revamp the main public health programs, Medicare and Medicaid. Each favors transitioning the former to a “premium support” or voucher system, in which seniors would receive a fixed amount to purchase their own plan, and traditional fee-for-service Medicare would be one option among a variety of private options. These candidates also envision funding Medicaid via federal block grants so that, as Santorum’s campaign site puts it, “states aren’t burdened by unfunded, crippling, one-size-fits-all federal mandates” and they can “implement solutions to address their unique healthcare needs.”
For his part, Ron Paul famously refused to accept either Medicare or Medicaid payments when he was a practicing physician in Texas. Instead, he provided charity and reduced-fee care for those patients who couldn’t afford his regular charges.
Proponents of this kind of patient-centered, don’t-tread-on-me healthcare argue that it not only empowers patients but creates real market competition and lower costs as consumers move to reward quality and efficiency. Critics argue that that’s fine, except it leaves too many of the sickest and most vulnerable Americans adrift, subjecting them to the vagaries of the marketplace and compelling their fellow citizens to pick up the tab.
Other Departures From the ACA
Both the ACA and the GOP candidates contend that the current medical liability system is flawed.
But whereas the ACA calls for a series of state-level demonstration grants for the purpose of developing, implementing, and evaluating alternatives to the current system, the GOP hopefuls would go further. Three — Romney, Santorum, and Gingrich — have called for significant medical liability reform, including caps on noneconomic damages. Libertarian candidate Ron Paul would ensure “fair compensation” for those injured during medical treatment, while “reducing the costly burden of malpractice litigation…by providing a tax credit for ‘negative outcomes’ insurance purchased before medical treatment.”
Each of the leading GOP primary contenders has also come out in favor of repealing the ACA’s controversial Medicare Independent Payment Advisory Board, the 15-member panel charged with curbing Medicare costs should they rise above a certain limit. Congressional Republicans have already started down this road, of course. And the American Medical Association (as well as at least 1 top Democrat, Rep. Frank Pallone of New Jersey) supports the repeal.
To see a concise chart showing the GOP candidates’ views on key issues of healthcare reform, , click here , and for a thumbnail sketch of the ACA pertinent features, click here .
From Medscape Business of Medicine
http://www.medscape.com/viewarticle/759602
Posted: 3/8/2012
Survey: 9 in 10 doctors won’t recommend profession
Survey: 9 in 10 doctors won’t recommend profession
by Dan Verel
A new survey found that nine out of 10 physicians across the country are unwilling to recommend the profession to others, while 43 percent said they are contemplating retirement as a result of “transformative changes” in the health care system — results that will likely exacerbate a well-documented nationwide physician shortage.
The Doctors Company, the largest physician and surgeon medical liability insurer in the county, surveyed more than 5,000 of its members for “The Future of Health Care” and found that the “overwhelming indication” is current physician sentiment will make the shortage all the more difficult, but critical, to confront.
With the federal Affordable Care Act taking shape over the next several years, some 32 million Americans will enter the health care system by 2014, which will add further strain in the industry. And while health experts have long warned of the shortage, particularity as it relates to primary care, The Doctors Company survey found the troubling sentiment to be spread relatively even across the field of medicine — not just primary care.
“We surveyed a cross section of our membership and received responses from a relatively even number of primary care, surgical specialty and nonsurgical specialty physicians,” said Dr. Richard Anderson, chairman and CEO of The Doctors Company, based in Napa. “The challenges to primary care are well known and are a major problem with or without health care reform. The responses from primary care physicians and specialists were similar in direction and tone.”
Recent efforts to address the simultaneous influx of patients and shortage of physicians include WellPoint, the nation’s largest health insurance carrier, raising its reimbursement rates for primary care. Other efforts include increasing usage of nurse practitioners and other so-called “physician extenders” to address the rise in patient volume, a development that will likely continue, health experts said.
“There is no question that physician extenders will have an important role to play in the future of health care,” Dr. Anderson said. “Right now, their role is governed by a mismatch of clinical practice, state laws and local customs. Until we come to grips with this on a national basis, there will be no simple answer for this question.”
Likewise, with higher reimbursement rates, Dr. Anderson said that it’s a step in the right direction but by no means is a cure-all.
“More appropriate compensation for primary care is certainly welcome. Compensation trends, however, tend to be a zero-sum game. Where do the dollars come from then?” he said.
Mark Knight, a health care consultant and former vice president of strategic services for Northern California for St. Joseph Health System, said the findings of the new survey were surprisingly high but not all that shocking given the health care landscape.
“That’s higher than I would have guessed,” he said, citing a similar 2010 New England Journal of Medicine survey that put the number at 63 percent. “That’s quite a change in a two-year period.”
Mr. Knight echoed many of the survey’s findings, noting that physicians increasingly struggle with insurance reimbursement rates and burdensome debt from their eduction. But, he said, overtime the landscape is likely to change, and younger physicians will have much different expectations as they shift toward the managed care model and away from private practice.
Across California, health systems and hospitals have attempted to address the matter by increasingly merging, aligning or consolidating with physician foundations and HMOs, or creating accountable care organizations that are encouraged under health care reform. Hospitals in particular have invested heavily into physician foundations, partly as a means of retaining physicians, Mr. Knight said.
Only 20 percent of respondents said they were planning to change their practice models over the next five years; of those, the majority said they would likely pursue a larger practice model, according to Dr. Anderson. Another 24 percent of respondents did not select a future practice model, “suggesting that respondents feel substantial uncertainty about their prospects,” Dr. Anderson said.
And 57 percent of respondents said they were undecided on whether they would participate in an ACO, according to the survey. Another 51 percent were either undecided or needed more information about patient-centered medical homes before considering them.
One potential benefit of larger group practice, Dr. Anderson said, is the “cross-subsidization of specialties within a group.”
The Doctors Company has some 71,000 members nationwide.
To view the survey, go to www.thedoctors.com/KnowledgeCenter/Publications/CON_ID_004672.
From North Bay Business Journal
http://www.northbaybusinessjournal.com/50520/survey-9-in-10-doctors-wont-recommend-profession/?tc=ar
Posted: 3/12/2012
Alcohol may not be the only thing blurring your vision these days…
Does Drinking Coffee Increase Glaucoma Risk?
Neil Canavan
An analysis of the health records of more than 75,000 women has found a positive association between heavy coffee drinking and the development of exfoliation glaucoma (EG) or EG suspect, according to data presented here at the American Glaucoma Society 22nd Annual Meeting.
“We believe that coffee consumption is a reasonable candidate to consider,” said lead investigator Louis Pasquale, MD, FARVO, associate professor of ophthalmology at Harvard Medical School in Boston, Massachusetts.
Dr. Pasquale explained that previous randomized trials have indicated that homocysteine levels, a risk factor for coronary disease, are increased after coffee consumption, and that patients with EG have elevated homocysteine in the aqueous humor and tears.
Dr. Pasquale and colleagues used data collected in the Nurses’ Health Study from 1980 to 2008 for their study. To be included, subjects had to be at least 40 years of age, had to have no history of glaucoma or cancer, and had to have reported eye exams.
Patients were identified as having EG if there was evidence on a slit-lamp exam and 2 or more reliable visual fields showing reproducible loss. For patients with EG suspect, the presence of exfoliation material on the slit-lamp exam was required, as was an intraocular pressure (IOP) above 21 mm Hg or a cup-to-disc ratio of 0.6 or higher.
A validated questionnaire was used to assess total caffeine intake (from coffee, tea, soda, and caffeine-containing food) every 4 years. A multivariate analysis was performed to determine the association between caffeine consumption and the incidence of EG.
The investigators found 300 cases of EG over 1.6 million person-years of follow-up.
Women who consumed 500 mg caffeine or more per day (1 cup of coffee has roughly 150 mg of caffeine) had a nonsignificant but numerically increased risk for EG (P = .06), compared with those who consumed less than 125 mg per day.
People who drank 3 or more cups of coffee daily had a relative risk (RR) for EG of 1.63 (95% confidence interval [CI], 1.03 to 2.57; P = .02), compared with those who abstained from drinking coffee.
The association between coffee intake and EG was stronger in people with a family history of glaucoma (RR, 2.9; CI, 1.16 to 7.47) than in people with no family history (RR, 1.16; CI, 0.27 to 1.88).
“This strongly suggests that there is a gene interaction with the environment at play here,” Dr. Pasquale said.
Given these data, which he cautions are preliminary, Dr. Pasquale does not think that routine checking of homocysteine levels or advising changes in coffee consumption are warranted until stronger associations are proven.
Moderation in All Things
A second study reported here at the American Glaucoma Society meeting was an investigation of the effect of modest caffeine intake — one 8 oz (237 mL) cup of coffee — on IOP.
“Studies in the past have shown conflicting evidence about IOP and caffeinated coffee,” explained Aliya Jiwani, BA, from the Massachusetts Eye and Ear Infirmary in Boston. “To date, there are no double-blind randomized controlled trials that examine the effect of coffee on IOP, ocular perfusion pressure [OPP], or ocular pulse amplitude [OPA] in those who have glaucoma or those at risk. This is the first trial of its kind.”
This prospective investigation involved 106 subjects — 22 with high-tension primary open-angle glaucoma (POAG), 18 with normal-tension POAG, 20 with ocular hypertension, 21 with suspected POAG, and 25 healthy control subjects.
Randomized subjects ingested 8 oz of either caffeinated (182 mg) or decaffeinated (4 mg) coffee at the first clinic visit; at the second clinic visit, they ingested the alternate beverage. Blood pressure, IOP, OPA, and heart rate were measured before and 60 and 90 minutes after coffee consumption. The investigators calculated OPP (from blood pressure) and IOP.
At baseline, there were no differences in IOP, OPP, or OPA between treatment groups. Sixty minutes after caffeinated coffee intake, mean change in IOP was 0.99 mm Hg (P < .001), in OPP was 1.06 mm Hg (P < .001), and in OPA was 1.57 mm Hg (P = .013). Ninety minutes after caffeinated coffee intake, mean change from baseline in IOP was 1.26 mm Hg (P = .039), in OPP was 0.23 mm Hg (P < .001), and in OPA was 0.18 (P = .001).
Regression analysis revealed sporadic and inconsistent associations between caffeine intake and increases in IOP, OPP, and OPA.
“Although caffeine did have an observable effect in this cohort,” Ms. Jiwani explained, “these 1-time modest increases are unlikely to have a clinical impact on this population.”
From Medscape Medical News
Posted: 3/6/2012
Ten Physicians Indicted as Fronts for ‘Russian Criminals’
Authors and Disclosures
Author
Robert Lowes
Robert Lowes is a journalist for Medscape Medical News. A former senior editor at Medical Economics magazine and contributor to numerous healthcare publications, Robert has covered medicine from almost every conceivable angle — public policy, managed care, education, ethics, medical malpractice, information technology, billing and collections, waiting-room design, and first-degree murder. His articles have won major awards such as first place in the annual journalism competition of the National Institute for Health Care Management, and several have been republished in books. Robert also is an anthologized poet. He can be contacted at rlowes@medscape.net.
From Medscape Medical News
Ten Physicians Indicted as Fronts for ‘Russian Criminals’
Robert Lowes
Posted: 2/29/2012
A grand jury has indicted 10 physicians and 26 others in a New York City federal court on charges of trying to rip off automobile insurers to the tune of roughly $279 million, and making off with about $113 million.
As in many other recent healthcare fraud cases, physicians are not the ringmasters in this alleged criminal enterprise. Rather, the indictment, unsealed today, states that they are fronts and underlings for a cadre of nonphysicians, primarily “individuals of Russian descent” with Mafia-style nicknames like “Russian Mike,” “Fat Mike,” “Skinny Mike,” “KGB,” and “Nose.”
The nonphysician defendants are accused of operating more than 100 clinics — “medical fraud mills,” in the words of the indictment — in the New York City area that billed auto insurers for treating patients involved in car accidents. In general, the accidents were real, not staged. However, the treatments were either never provided or were unnecessary, according to the indictment.
Authorities call the clinics “no-fault clinics” because they were reimbursed by auto insurers under a no-fault law in New York that entitles accident victims to as much as $50,000 in medical benefits regardless of who caused the accident.
State law also requires all medical clinics to be owned and operated by a licensed medical practitioner. To skirt that restriction, the nonphysician defendants calling the shots paid the physician defendants a fee, a salary, or both, in exchange for pretending to be the owner-operators. The physicians essentially lent their signature for the sake of incorporating a clinic, opening a bank account in its name, and leasing property.
The physicians also signed insurance claims for treatment under the no-fault law, wrote excessive and unnecessary prescriptions, and referred patients to other “fraudulent clinics” for MRIs, X-rays, acupuncture, chiropractic therapy, pain management, and durable medical equipment, all with the goal of running up the tab to $50,000. These secondary or “modality” clinics also were owned by ringleader defendants, according to the indictment.
In a press conference today, Preet Bharara, the high-profile US attorney for the Southern District of New York, highlighted the role of the physicians in what he called a “colossal” fraud.
“The scheme relied on a cadre of corrupt doctors who essentially peddled their medical licenses like a corner fraudster might sell fake IDs, except those medical licenses allowed unlawful entry, not to a club or a bar, but a multibillion dollar pool of insurance proceeds,” said Bharara, who recently made the cover of Time magazine for his crime-fighting exploits.
New York City Police Department Commissioner Raymond Kelly described the physicians’ compensation as easy money.
“A real doctor would be paid a monthly retainer, up to $10,000, to show up just to sign referrals,” said Kelly.
Finder’s Fee of Up to $20,000 for a Willing Physician
The 10 physicians named in the indictment are:
- Sergey Gabinsky, MD
- Tatyana Gabinskaya, MD
- Joseph Vitoulis, DO
- Lauretta Grzegorczyk, MD
- Eva Gateva, MD
- Zuheir Said, MD
- David Thomas, MD
- Billy Geris, MD
- Mark Shapiro, MD
- Robert Della Badia, MD
The physicians, along with 2 chiropractors and 2 acupuncture practitioners, were charged with conspiring to commit healthcare and mail fraud. They face a maximum penalty of 30 years in prison.
The clinicians answered to a group that one FBI official today described as “Russian criminals.” They recruited the physicians — offering a finder’s fee of up to $20,000 — and hired “runners” who were paid up to $3000 for every accident victim they could bring in for treatment, according to authorities. They also referred patients to attorneys who filed personal-injury lawsuits and in turn paid the ringleaders thousands of dollars in kickbacks. The attorneys encouraged patients to receive more treatment to strengthen their court case.
This “no-fault organization” consisted of 2 allied branches, according to the indictment. One was directed by Mikhail Zemlyansky (“Russian Mike”) and Michael Danilovich (“Fat Mike”) and the other by Yuriy Zayonts (“KGB”) and Mikhail Kremerman. They and 4 other individuals, including attorney Matthew Conroy, were charged with racketeering and conspiracy to commit money laundering as well as conspiracy to commit healthcare and mail fraud.
The rest of the 36 defendants, which included 2 other attorneys, were charged with different combinations of the above charges, except for racketeering.
Top 12 Healthcare Quality Concerns in 2012
Top 12 Healthcare Quality Concerns in 2012
Cheryl Clark, for HealthLeaders Media
Posted: 1/4/2012
Which quality issues will provoke the most influential changes in healthcare in 2012? Or, which ones will most rapidly accelerate the graying of chief quality officers’ hair? There are so many, it’s hard to pick the most significant. We interviewed quality experts around the country to glean the most influential and then picked a dozen.
Here’s the list:
1.Patient experience scores hinge on “always” responses
The value-based purchasing sweepstakes have begun, with the first performance period for clinical process of care and HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) questions scheduled to end March 31. Payment adjustments will begin for patients discharged as of Oct. 1, and the winners and losers will then be revealed.
What makes many hospitals and clinical nurse managers most nervous, however, is that the patients responding to these surveys must reply “Always,” in order for the hospital to get credit for high quality patient experiences. Responses “Sometimes,” or “Usually” aren’t going to cut the mustard.
“How often did nurses listen carefully to you?” “How often did doctors treat you with courtesy and respect?” “How often was your pain well controlled?”
“Always.”
And by the way, Jan. 4, 2012 is the data submission deadline for patients dishcharged in July, August and September, 2011.
2. Physician Compare
As if providers didn’t already have enough to worry about with Medicare, Medicaid and private insurer payment reductions, electronic medical record and meaningful use compliance, disclosing payments from durable equipment and pharmaceutical companies and yes – remembering to answer their patients’ e-mails. Now they have something else to fret about.
As of this New Year’s Day, according to the Patient Protection and Affordable Care Act, the official reporting period begins for physician performance on quality and patient experience measures for physicians enrolled in Medicare on Physician Compare.
Starting “no later than” next New Year’s Day, 2013, the Health and Human Services Secretary shall “implement a plan” to make publicly available on Physician Compare a huge number of quality scores.
They include measures from the Physician Quality Reporting Initiative, an assessment of each physician’s patients’ health outcomes and their functional status, an assessment of the continuity and coordination and care and care transitions including episodes of care and resource use, efficiency, patient experience and patient, caregiver and family engagement, safety, and effectiveness and timeliness of care.
And if all that weren’t enough, the HHS secretary gets to publish other information on Physician Compare he or she determines appropriate.
3. Thirty-day Readmissions
A number of decisions forthcoming this year focus on how the Centers for Medicare & Medicaid Services will determine those hospitals with higher rates of readmissions for congestive heart failure, pneumonia and heart attack diagnoses. One question is whether the agency will compare a hospital’s readmission rates with just those within that hospital’s state, or whether each hospital will be compared with the entire country as a whole.
The first option would guarantee that some hospitals in each state would receive negative reimbursement adjustments (CMS prefers that we not use the word penalty), even if those hospitals have far lower readmission rates than hospitals with the highest rates.
Another issue up for consideration is the risk adjustment criteria, whether payers including private insurance companies will begin looking at all-cause readmission rates and whether scheduled readmissions will continue to be included in the equation.
The penalties start at 1% for Medicare DRG discharges on or after Oct. 1, 2012, increase to 2% on or after Oct. 1, 2013 and to 3% on or after Oct. 1, 2014.
How hospitals, physicians, discharge planners, nurse case managers, skilled nursing facilities and in-home health services agencies will work together to avoid the “blame game” when a patient does end up as an “avoidable” readmission will be interesting to watch.
Look for providers and federal regulators to talk more about “all-cause” readmissions, or to include additional diagnoses such as hip replacements gastrointestinal resections, and eventually to lengthen the watch period to 60 or 90 days.
How aggressively will hospitals and doctors stress the need for patients to comply with physician appointments and medication regimens? Will hospital staff dare to tell patients that if there is a preventable readmission, it make the hospital look bad and hurt the bottom line?
4. Outcome measures versus process measures
The science of testing outcomes versus surrogate “process” measures will evolve, but this year and years to come, much more rapidly.
Starting in FY 2014, CMS will include 30-day mortality measures in value-based purchasing incentive payment algorithms. But don’t expect publicly reportable outcome measures to stop there.
As James La Belle, Corporate VP of Quality, Medical Management and Physician Co-Management for Scripps Health explained, perhaps more meaningful metrics might include those covering “functional status,” such as how quickly or completely a patient’s cognitive function is restored, how far they can walk without assistance or how soon they can return to work. How long before the patient could say life was back to normal?
5. Meaningful Use
With the impending release of the Stage 2 Meaningful Use final rule, physicians and others have no more excuses to delay learning and installing software and computerized physician order entry systems.
If you listen closely, you will hear their cries, that they have been turned from being doctors to being typists. That they hardly ever get to see their patients because their heads are blocked by a computer monitor. Quality wonks will want to see evidence that these systems are time-efficient and not intimidating.
Look for applications that use hand-held tablets that are not just patient and doctor friendly, but actually fun to use and may make documentation seem more like a game.
6. Release of the Medicare claims database
Without much fanfare, CMS on Dec. 5 released its final rule governing how it would release, and who might obtain, access to its enormous claims database. This is a goldmine for any public or private entity that wants to “datadive” into numbers to evaluate cost as well as performance.
CMS’ final rule specifies that those selected to receive this information – and CMS will pick which ones – are expected to “increase the transparency of provider and supplier performance, while ensuring beneficiary privacy.” It is to be used to evaluate performance of providers and suppliers on quality, efficiency, effectiveness measures as well as use of resources.
The only catch is that the data may not be used by itself, but must be combined with health plan or other provider claims and quality information for performance measurement.
Medicare officials acknowledged in a statement that the final rule governing access to this treasure trove ends a situation that has been “frustrating” to providers and employers, consumers, and health care quality advocates.
7. Drug shortages and grey market vendors
Quality leaders are looking nervously at all the drugs that they can’t get or can’t afford to get because of price gouging – as much as 4500% – by grey-market vendors, and what drugs can be safely substituted. The problem involves the word “safety.”
According to a survey from the purchasing and quality group Premier Healthcare Alliance, the number of drugs with exceptionally high markups because of scarcity numbered only about 50 five years ago. But now the number is approaching 400.
“When these drugs are bought and sold across state lines, moved in whole or partial lots, repackaged and relabeled, resulting in a complex web of transactions involving dozens of trading partners, (it makes) it almost impossible to determine the supply source or authenticity,” said Premier’s COO Mike Alkire during a news conference in mid-August.
In a commentary for HealthLeaders Media online April 15, Alkire wrote:
“Drug shortages present a danger to public health. In hospitals, a shortage may delay necessary medical procedures. Substitution of similar medications, if available, may lead to errors and adverse events, especially if prescribers are unfamiliar with the alternative products’ dosing and potential interactions with other drugs.”
8. ICD-10
Our list would not be complete without a tip of the hat to ICD-10 adoption efforts, scheduled to go into high gear later this year in anticipation of the Oct. 1, 2013 date for the big switch.
Quality and chief information officers say this effort is monopolizing large chunks of their workday, even as the costs for installing and understanding the system make everyone nervous.
Down the line, however, ICD-10 data will gather power with volume datasets and enable providers to capture much more precise information on patients’ conditions and procedures. It will be tougher for hospitals to lump patients into more severe categories, a current practice that may enable higher reimbursement, will more quickly identify fraud, waste and abuse in healthcare and will enable better hospital and physician quality comparisons.
9. Emergency department speed, accuracy
Much of what happens to patients in hospital settings happens to them first in the ED. So it matters a lot how long they have to wait to be seen, how long it takes to correctly diagnose them with labwork, imaging or other functional tests, and how long it takes to process the paperwork, get them in an inpatient bed and provide whatever medications or procedures they need.
But until very recently, there have been very few ways in which ED quality has been formally measured, other than in time to antibiotic for a pneumonia patient, or door to balloon for heart attack patients.
That is about to dramatically change. In the next year, the Centers for Medicare and Medicaid Services will require hospitals to begin tracking and reporting their median times for two National Quality Forum benchmarks in emergency care.
1. The number of minutes between the “door,” the time the patient arrives at the ED to the moment they “depart” the premises of the ED to be admitted to the hospital
2. The time between the moment a decision is made by the ED physician to admit the patient to a hospital bed to the time the patient departs the ED and is actually placed in an inpatient bed, a period sometimes referred to as “boarding.”
Look for these results to become publicly reported on Hospital Compare. For now, CMS has not said it will impose a payment adjustment or penalty for slower hospitals, but that may come with future Outpatient Prospective Payment System rules, perhaps the one released for 2013.
Along the way, hospital emergency room providers, including physicians and nurses, are gathering consensus over terminology, so that everyone means the same thing when a patient is said to come in the “door.”
10. End-stage renal disease quality measures
Last month, the federal government released the first round of payment penalties for dialysis centers with lower scores on quality measures and one in three, or 1,300 of the 5,000 dialysis centers in the country made the list. This is a big deal for all providers
This is huge, because more than a half a million patients in the United States are on dialysis, and the federal government pays the bill for 453,000 who lack private insurance, at an average cost of between $57,639 and $77,506 per patient per year as of 2008. More quality measures will be added to the formula in 2014.
11. Medication management
Making sure that providers who treat patients who need to be on multiple medications for multiple conditions talk to other members of the team to make sure the patients, especially the elderly, are not being prescribed harmful combinations.
A recent report in the New England Journal of Medicine study found that 100,000 seniors a year require costly, emergency hospitalization because of misuse and adverse reactions to of prescription drugs, with four medications responsible for 67%, either alone or in combination.
Additionally, keeping patients compliant with their regimen, communicating with pharmacies, and making sure that patients are on the correct medications when they’re discharged from the hospital –– not necessarily the same ones they took before they were admitted – will be an increasing challenge for providers.
12. Waste, fraud, and abuse
In November of 2010, the Office of Inspector General’s report found that of nearly one million Medicare beneficiaries discharged from hospitals in just one month – October of 2008 – one in seven experienced an adverse event and nearly half of those were preventable medical errors, substandard care and inadequate patient monitoring and assessment. This is one category of avoidable spending.
Another is the fact that far too many patients are getting unnecessary procedures, including surgery or undergoing care with the use of new “better” technology that really isn’t.
In his address at the Institute for Healthcare Improvement forum in Orlando last month, outgoing CMS administrator Don Berwick, MD, called it “overtreatment – the waste that comes from subjecting people to care that cannot possibly help them – care rooted in outmoded habits, supply-driven behaviors, and ignoring science.”
What the Patient Centered Outcomes Research Institute, PCORI, does this year when it begins to prioritize its research hospitals projects may make some providers nervous, especially if the results of that research throw doubt on a key line of service or major device acquisition.
That’s our list, although undoubtedly there are other worthy candidates we could have included. Can you suggest others? If so, please do so in the comment section below or send me an e-mail. Maybe we’ll have enough for a sequel.
Happy New Year.
Florida Hospital settles Medicare overbilling allegation
From Orlando Business Journal
Florida Hospital settles Medicare overbilling allegation
Posted: 2/8/2012
Florida Hospital is among 14 institutions paying more than $12 million to end an inquiry into whether spinal procedures were improperly moved from outpatient to inpatient to overbill Medicare,the U.S. Department of Justice announced Feb. 7.
Florida Hospital will pay $3.9 million — more than any other institution involved in the current round of settlements — to settle the allegations at four facilities: Florida Hospital Orlando, Florida Hospital Oceanside, Florida Hospital Fish Memorial and Florida Hospital Heartland Medical Center. The settlements resolve allegations that the hospitals overcharged Medicare between 2000 and 2008 while performing kyphoplasty, a minimally invasive procedure used to treat certain spinal fractures, according to a press release.
In many cases, the procedure can be performed cheaper as an outpatient procedure. The government contends that the hospitals performed the procedure on an inpatient basis in order to increase their Medicare billings. The Justice Department has reached settlements with more than 40 hospitals totaling more than $39 million to resolve false claims allegations related to kyphoplasty claims submitted to Medicare. These settlements follow the government’s 2008 settlement with Medtronic Spine LLC, corporate successor to Kyphon Inc., which paid $75 million to settle allegations that the company defrauded Medicare by counseling hospital providers to perform kyphoplasty procedures as an inpatient procedure even though the procedure should have been done in many cases on an outpatient basis.
Florida Hospital did not return immediate requests for comment. The other hospitals involved in the settlement are:
• Gulf Coast Hospital, Fort Myers ($173,005.86)
• Lee Memorial Hospital, Fort Myers ($159,571.87)
• Cape Coral Hospital, Cape Coral ($73,279.47)
• Plainview Hospital, Plainview, N.Y. ($2,307,265)
• North Shore Syosset Hospital, Syosset, N.Y. ($192,735)
• North Mississippi Medical Center, Tupelo, Miss. ($1,894,683.30)
• Mission Hospital, Asheville, N.C. ($1.5 million)
• Wenatchee Valley Medical Center, Wenatchee, Wash. ($1,224,709.96)
• Community Hospital Anderson, Anderson, Ind. ($500,561.36)
• St. John’s Mercy Hospital, Creve Coeur, Mo. ($365,000)
http://www.bizjournals.com/orlando/news/2012/02/08/florida-hospital-to-pay-39m-settle.html
Death by a Thousand (Paper) Cuts
Authors and Disclosures
Auhtor
Jeff Bocan
Managing Director, Beringea, LLC
From The Huffington Post > Business
Death by a Thousand (Paper) Cuts
Jeff Bocan
Posted: 1/30/2012
Is your doctor putting your health at a risk?
According to a recent study published in the New England Journal of Medicine, your doctor could unintentionally be offering you and your family sub-optimal care if he/she is still using paper records to document important medical and patient information. The study found that patients in physicians’ practices that used electronic medical records (EMRs) not only received better and more thorough care, but had better health outcomes than those in practices using paper records.
If this post was a Tweet, it would simply read: “EMRs = Better Health. Paper Medical Records Bad”. But, dear reader, you are smart enough to know that the story is much more complicated than that… Of course, there are amazing doctors who still cling to their paper records and filing systems and there are less-than-amazing doctors that are running full patient loads on digital EMR systems. But to me, the study highlights a conundrum that has been stuck in my craw for months… It is undeniable that technological advancements have radically improved patient health outcomes over the last 50 years — the improvement in life expectancy alone is a triumph for health care providers. For decades, doctors have been incredibly successful at adopting new technologies and integrating the new methods into their practices and we are all better off for it. But why, oh why, is the medical profession moving in slow motion joining the rest of the nation in the digitalization of their business practices?
Sure, electronic medical records that can enable seamless, instant portability of records between doctors and mitigate lethal prescription errors and reduce expenses of the medical system aren’t nearly as sexy or fun for doctors as the latest robotic surgical tool. But if a doctor’s primary goal is to improve public health and patient outcomes, then a rapid migration of the health care industry from the stodgy filing cabinet-filled rooms of paper files to the dynamic world of digitized medical records is perhaps one of the single most impactful actions a doctor can make to improve health care for all of us.
If your doctor is not digital yet, they probably have their reasons. Many physicians cite the cost of implementation, data security concerns and a lack of support staff as factors keeping them from making the switch. Although all these concerns are legitimate, legislation and recent developments in the healthcare IT industry have helped mitigate most of these fears.
One of the smartest elements of recent health care reforms has been the Obama administration’s effort to gain 100 percent compliance with electronic records among doctors. It backed this imperative by earmarking $20 billion of the infamous 2009 stimulus bill to make the transition to EMR financially feasible for doctors. Just this year, doctors who have implemented EMR solutions have already started to receive incentive checks to cover much of the expense of going digital. Stimulus funds coupled with flexible low monthly payment options from many EMR providers have made the cost of going digital no longer an excuse to not make the switch.
Data security is valid concern by both patients and doctors, which is why EMR providers have taken important steps to ensure medical information is safe and secure. Many EMR products have built-in security measures similar to the banking industry and include features such as data encryption, secure logins and live audit feeds that track every action within the EMR database. The industry must remain vigilant when it comes to security, but the current security risks don’t justify being stuck in the past. Just imagine the world if the airline/finance/retail/etc. industries used this excuse to stick to paper processes.
Currently, there are more than 230,000 physician practices in the United States, more than half of which are single doctor practices. According to a study conducted by Kalorama, these single physician practices have the lowest EMR adoption rates, at only 20.6 percent. Unlike large group practices that have dedicated office administration staff to support EMR implementation and use, single doctor practices historically have found migrating from paper to digital to be difficult and time-consuming. However, some EMR products are much more intuitive now, especially those that are easy to implement like gloStream‘s familiar Microsoft-based system which guarantees that doctors will be operating at full patient loads within 15 days of implementation. Because many single doctor practices are already familiar with the software, they can convert their full patient load quickly without a lot of technical and administrative support. (Full disclosure, I am on the gloStream board — hence my passion for the topic!).
The fact that the same paper recording keeping practices used 50 years ago are still in use today by nearly half of all doctors astounds me. Admittedly, admin-related issues are the least exciting elements of any doctor’s practice — but doctors would be doing us all a favor by going digital. C’mon, docs! Make EMR integration a priority!
http://www.huffingtonpost.com/jeff-bocan/electronic-medical-records_b_1197195.html
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