HealthBlawg

Extra! Extra! Health Wonk Review hits the newsstands!

Newsie Jason Shafrin hosts the latest edition of Health Wonk Review at his Healthcare Economist blog.

-- David Harlow

Study says Massachusetts medical malpractice insurance premiums aren't as bad as we think

Marc Rodwin, in his Health Affairs piece on Massachusetts malpractice premiums out this week, says the supposed malpractice crisis just isn't there.

Inflation-adjusted premiums are about where they were 30 years ago; they've gone up -- and down, in cycles -- over the past three decades.  Furthermore, Massachusetts compares well to other states on premiums, even though we're near the top of the range for recoveries.  See the Boston Globe article on this piece, too. 

However, not all is rosy.  Newly-installed Mass. Medical Society President Bruce Auerbach noted in the Globe article that there are issues beyond malpractice insurance premiums that make practice in Massachusetts challenging. 

In a conversation yesterday with the HealthBlawger, Dr. Auerbach said that Rodwin's conclusions need to be examined in a broader context:  declining inflation-adjusted physician income and increased cost of living and practice costs (beyond malpractice insurance expense).  He also identified the need for tort reform as a key issue. See MMS's reports on these subjects and more here. 

While Rodwin's analysis looked at size of malpractice recoveries (relative to other states and over time), there are some other aspects of tort reform that Auerbach says warrant further attention (the MMS has sponsored state legislation to address many of these issues as well as some others): (1) elimination of joint and several liability in med-mal cases (which socks docs with more liability thanks to the Massachusetts limitation of liability law for nonprofits, including most hospitals here); (2) promoting apologies; (3) requiring large payouts to be made over time; (4) requiring reports of recoveries to the Betsy Lehman Center in order to help improve safety through evidence-based medicine.

Rodwin's article contains a wealth of information and analysis -- more than I can do justice to here.  From the perspective of the practicing doc, though, insurance premiums are just one piece of the puzzle, and all of the pieces need to be moved around -- just as in the case of the Massachusetts universal health insurance law we talk about coverage, access and quality: one piece of that puzzle has been addressed, and now the others need to be tackled.      

-- David Harlow

Grand Rounds is up at Health Business Blog

Fellow Bostonian David Williams hosts this week's Grand Rounds at his Health Business Blog.  He says it's his fifth time doing the honors . . . .  Who knew Nick Genes was old enough to have kept this going for so long?

-- David Harlow

Blawg Review: the whistleblower edition

Forget Bogey and Bacall.  Head straight over to the Whistleblower Law Blog for the latest edition of Blawg Review, livened up this week with some nursery rhymes.

-- David Harlow

OIG nixes test tube labeling service by lab seeking dialysis center business

The OIG released an advisory opinion last Friday finding that a lab's practice of labeling test tubes for free in order to get dialysis center business -- to be initiated because "all the other labs are doing it" -- could be considered an illegal kickback intended to induce referrals (though the OIG, of course, does not inquire into intent in the course of the advisory opinion process).

So were the owners of the lab that requested the opinion really planning to implement this approach, or was this simply a ruse to smoke out the competitors and get them to stop, thus leveling the playing field?  Only their lawyer knows for sure . . . .

-- David Harlow

The good, the bad, and the different: accessing health care services on vacation overseas

While on vacation in Israel last month, I had occasion to sample the local health care system.  My teenage son needed an antibiotic, to nip in the bud a recurring respiratory issue.  Fortunately, I had noticed a neighborhood health clinic a couple of blocks from the apartment we were renting in Ramat Gan, a Tel Aviv suburb.  My wife took him into the clinic in the late morning (he sleeps like a teenager, regardless of time zone).  After a little intake dance (and discussing Blue Cross Blue Shield coverage in a country with national health insurance), a nurse determined that he probably needed an antibiotic, but that he would have to be seen by one of the physicians before a prescription could be written.  (What, no NPs? No PAs?)  It was 12:05.  Unfortunately, she came back a few minutes later to report that the docs had all left the building at noon, so -- no chance of getting a prescription.

The options: go to a clinic in another nearby suburb (the nurse called ahead and determined that it was unclear whether, or for how long, a doctor would be there) or head to a nearby emergency room.  The nurse recommended the emergency room: "All the tourists go there."

I drove the ten or fifteen minutes to Tel Hashomer Hospital.  It is a giant university medical center, with about 20% of the signage one might expect.  It took me a while to find the pediatric emergency department (after a brief, but heated, argument about parking).

Once in the pedi ED, service was quick, and -- take note, ED administrators everywhere -- nobody asked about source of payment prior to service.  (That may have canceled out the delay in care due to lack of signage.)  The triage nurse seemed to be the sort of person every physician asks to run interference with other nurses and other hospital departments, so it took her a while to get through the history.  My son was seen almost immediately by a physician who ordered a chest x-ray (done down the hall, image transmitted via PACS back to her workstation), and a nebulizer treatment (in a room designed to accomodate multiple patients at once, including one whose mother found it a convenient spot for breastfeeding).  The doc sent us off with a prescription (to be filled at the "Super-Pharm" in the next hospital building).

Oh, and on the way out, the unit clerk validated my parking ticket and said she'd mail out a form for me to have signed and returned by my PCP.  Then she remembered I was a foreigner.  I waved my BCBS card -- again -- but she cheerfully informed me that the hospital did not deal with overseas insurance.  She printed a bill and I paid by credit card:  it was about $250 for an ED visit, including physician services, an x-ray and a nebulizer treatment.  (Not bad, eh?  The only excessive cost for the visit was the airfare . . . .)

It was after 4:00.  I picked up the antibiotic, and we headed back to the apartment to pick up the rest of the family and head south, five hours later than planned . . . .

When we returned to the States, I called BCBS.  The visit is covered; they're sending me a form to fill out and return with the hospital bill (it's in Hebrew, but they say they'll have it translated in Virginia). 

The hospital visit delayed our arrival at Shakespeare's Falafel Stand in Beersheba (yes, really), but it was an interesting peek into another country's health care system.  Still, I don't think I can deduct the trip as a business expense.         

-- David Harlow

No pay for more never events: CMS proposes more never events and more hospital reporting obligations

As part of the proposed 2009 IPPS regulation published in the April 30 Federal Register, CMS has issued a proposed expanded list of never events, and also proposed increasing hospital reporting obligations.  The CMS press release explains it all for you:

The rules proposed by CMS expand two key initiatives that begin to link payments for health care services to quality of care – the Hospital-Acquired Conditions and the Hospital Quality Measure Reporting initiatives.  Under the HAC initiative, beginning October 1, 2008, Medicare will no longer pay hospitals at a higher rate for the increased costs of care that result when a patient is harmed by one of several conditions they didn’t have when they were first admitted to the hospital and that have been determined to be reasonably preventable by following generally accepted guidelines.

The HAC provisions in Medicare regulations required hospitals to begin reporting on their Medicare claims on October 1, 2007, whether certain specified diagnoses were present when the patient was admitted.  The first eight conditions, which were selected last year because they greatly complicate the treatment of the illness or injury that caused the hospitalization, resulting in higher payments to the hospital for the patient’s care by both Medicare and the patient, were:

    * Object inadvertently left in after surgery
    * Air embolism
    * Blood incompatibility
    * Catheter associated urinary tract infection
    * Pressure ulcer (decubitus ulcer)
    * Vascular catheter associated infection
    * Surgical site infection- Mediastinitis (infection in the chest) after coronary artery bypass graft surgery
    * Certain types of falls and trauma

CMS is proposing to expand the list of conditions that need to be reported if present when a patient is first admitted and is seeking public comment on whether they should be added to the list in the final rule to be announced later this year.  The list in the proposed rule includes:

    * Surgical site infections following certain elective procedures
    * Legionnaires’ disease (a type of pneumonia caused by a specific bacterium)
    * Extreme blood sugar derangement
    * Iatrogenic pneumothorax (collapse of the lung)
    * Delirium
    * Ventilator-associated pneumonia
    * Deep vein thrombosis/Pulmonary Embolism (formation/movement of a blood clot)
    * Staphylococcus aureus septicemia (bloodstream infection)
    * Clostridium difficile associated disease (a bacterium that causes severe diarrhea and more serious intestinal conditions such as colitis)

Beginning October 1, 2008, Medicare will no longer pay the hospital at a higher rate for the original eight conditions or any conditions added to the list in the final rule, if they were acquired during the hospital stay.

The second initiative CMS is proposing is the expansion of the hospital quality measure reporting program, which reduces the amount a hospital is paid if it does not participate in the voluntary reporting of standardized quality measures.  These are measures that are publicly reported on Hospital Compare.  Hospitals are currently required to report 30 quality measures on their claims for Medicare inpatient services to qualify for a full update to their FY 2009 payment rates.  CMS is proposing to add 43 quality measures to the list in order to get the full inflation update for FY 2010, bringing the total number of measures in FY 2009 to 73.  The proposed additions include the measures of the following types:

    * Surgical Care Improvement Project (SCIP) – 1 new measure
    * Hospital readmissions – 3
    * Nursing care – 4
    * Patient Safety Indicators developed by the Agency for   Healthcare Research and Quality (AHRQ) – 5
    * Inpatient Quality Indicators developed by the AHRQ – 4
    * Venous thromboembolism measures (VTEs) - 6

You can read more on never events in other posts here at HealthBlawg.

-- David Harlow

CMS issues 2009 IPPS, takes another look at the "stand in the shoes" rule and solicits thoughts on gainsharing exceptions

On April 30, CMS published its draft 2009 IPPS regulation.  The inpatient prospective payment system reg is loaded down, as usual, with additional regulatory changes. 

Among the most highly touted are the quality of care initiatives. 

One of the CMS fact sheets on the reg highlights two other standout provisions -- the "stand in the shoes" and gainsharing proposals:

The physician self-referral rules prohibit physicians from making referrals for eleven types of designated health services (DHSs) furnished in facilities in which the physician or an immediate family member of a physician has an ownership interest or compensation arrangement, and prohibits the entity from billing Medicare or any other entity for services that were referred in violation of the ban.  The proposed rule would:

• Modify the physician self-referral “stand in the shoes” provisions in the definition of indirect compensation arrangement to: (1) accommodate certain financial transactions made between physicians and academic medical centers or integrated healthcare delivery systems; and (2) require a DHS entity to stand in the shoes of an organization in which it has a 100% ownership interest.
• Revise the definitions of "physician" and "physician organization."
• Clarify the period of time for which a physician would be prohibited from referring Medicare patients to an entity for DHS and for which the DHS entity would be prohibited from billing for such DHS (the “period of disallowance”) where a financial relationship between the physician and the entity failed to satisfy the requirements of an exception to the prohibition on physician self-referral.
• Solicit public comment on gainsharing arrangements and physician-owned implant companies about the extent to which these arrangements pose a risk for program abuse.

The federales' previous cut at a "stand in the shoes" rule was put on ice late last year, since it would have rendered impermissible many current relationships involving support payments between components of academic medical centers and integrated delivery systems.  The new version, which would be finalized by August, and take effect October 1, is described in greater detail in the Federal Register document, at page 23685 (page 159 of the linked document).

On the gainsharing front, there is no specific proposal -- rather, the federales are looking for suggestions (page 23694):

At this time, we decline to issue a specific proposal concerning an exception for gainsharing arrangements, but rather are soliciting comments as to whether we should establish an exception for gainsharing arrangements, and, if so, what safeguards should be included in the exception. Specifically, we are interested in receiving comments on: (1) What types of requirements and safeguards should be included in any exception for gainsharing arrangements; and (2) whether certain services, clinical protocols, or other arrangements should not qualify for the exception.

Gainsharing has been a topic of particular interest to me, and I look forward to seeing a wide variety of proposed models for gainsharing, and ultimately a regulatory exception broad enough to encompass them all.  Before a general exception is promulgated, however, it would be nice if CMS would actually grant final approval to the gainsharing demonstration projects (646 and 5007) for which it has granted preliminary approval; after all, experience in the demonstration projects was supposed to inform the ultimate decisions about broader exceptions.

-- David Harlow 

The Mommy Blawger does Blawg Review

With Mother's Day just around the corner, The Mommy Blawger hosts Blawg Review this week, in honor of International Midwives' Day.

-- David Harlow

David Harlow quoted on CMS recovery audit contractor (RAC) initiative

The Medicare recovery audit contractor (RAC) initiative is moving from pilot phase to national implementation, in stages.  See my earlier post on the RAC initiative, the CMS report on RACs issued in February, other CMS materials on RACs, and also a recent article in which I'm quoted, in the April issue of Orthopaedic Practice Management -- which appears in a slightly different form as the lead article in the May issue of Managed Care Contracting & Reimbursement Advisor. 

OPM is a publication of Oakstone Medical Publishing; MCCRA is a publication of HCPro.

As I noted in the article, RACs focused on hospital claims during the demo phase (since that's where the big bucks are) but now that the gloves are off, physician practices will feel the pinch more acutely.  The CMS materials outline the rollout schedule for national implementation.

Bottom line: implementing a comprehensive compliance plan will go a long way towards avoiding having to deal with the RACs.

-- David Harlow