05.20.09
Posted in Uncategorized at 1:01 am by amit
Pediatric Associates' compliance officer C. Rocky Slonaker, MD, breathed a sigh of relief when he heard that his practice would have more time -- until Aug. 1 -- to comply with the Federal Trade Commission's new identity theft prevention rules.
The "red flags" rules -- which require creditors to implement a formal policy for detecting and preventing identity theft -- were not on Dr. Slonaker's radar. It wasn't until the FTC last fall delayed the original Nov. 1, 2008, compliance date to May 1 that he became aware the rules also applied to the health care industry.
Pediatric Associates, a 21-office South Florida group practice, managed to formalize a plan by April 30, the day the latest three-month delay was annouced. The process largely involved enhancing existing privacy and security policies required by the Health Insurance Portability and Accountability Act.
"It wasn't a huge stretch, and [the extra time] gives us a buffer to see if our policy is doing what it's supposed to do," Dr. Slonaker said. "The biggest concern is, we want to make sure patient care doesn't come to a grinding halt."
That echoed at least some of the initial worry from organized medicine when the FTC indicated that physicians are considered creditors under the rules. The regulations were authorized under the 2003 Fair and Accurate Credit Transactions Act, which requires entities that regularly extend credit, or defer payment for services, to establish an identity theft policy.
The American Medical Association and several medical organizations continue to challenge what they believe is an overly broad legal interpretation by the FTC. Until the issue is resolved, however, organized medicine and legal experts urge doctors to get in compliance.
Finding flags
"These are legal requirements that take planning," said Yarnell Beatty, general counsel to the Tennessee Medical Assn. Doctors can face stiff fines for noncompliance, he warned.
The rules require physician practices to identify red flags, or warning signs, of potential identity theft occurrences, create a corporate policy for responding to such risks and train staff on the new policy.
"What's good about this [rule] is it allows customization and allows you to take into account experiences in your own medical practice," said John S. Mulhollan, a health care lawyer with Baker Hostetler in Cleveland.
HIPAA may be a good starting point, but the FTC rules require distinct security policies that focus more on financial data than medical data, Mulhollan said. Implementation also may prove more effective if a specific staff member is assigned to oversee the policy and procedures.
Pediatrics Associates already had a number of checks to verify a patient's information as well as the identification of parents or guardians, Dr. Slonaker said. Staff now take additional precautions and pay attention to other red flags, including:
- Documents that look altered or forged.
- Discrepancies in or absences of Social Security numbers or insurance cards.
- Records showing inconsistent information.
- Bills for services never rendered or insurance claims denials.
"The burden was more in reading the law and translating those expectations to health care," Dr. Slonaker said. He hopes a policy template promised in the FTC's latest announcement and planned for release on the commission's Web site will offer stronger guidance.
A reasonable approach
The Florida medical group tried to stick with what it considered reasonable practices. "If we are only allowed to give information over the phone on how to care for fever to a verified guardian, that's an access-to-care issue for me," Dr. Slonaker said. "But if it's just 'this is what we do for fever,' and we're not giving out any identifying information, it may not really matter if you were Johnny's mother or not."
Mona Reimers, a practice manager at Orthopaedics NorthEast, a multi-office practice in the Ft. Wayne, Ind., area, also said stringent prior HIPAA policies made compliance less of a hassle than expected. Because it is an orthopedic practice, individuals posing as patients to obtain narcotics came up as a common red flag. The group also tried to prepare patients by alerting them that certain administrative requirements were for their protection.
But Reimers anticipates the real challenge will come in updating the policy and training staff as new issues arise. The FTC rule also was ill-planned considering what appears to be an overlap with additional, forthcoming HIPAA requirements under the most recent federal stimulus package, she said.
"Of course we want to protect patient privacy. It's good business," she said. "But at a time when we're trying as a country to make administrative simplifications to lower health care costs, this [red flags requirement] went in a completely opposite direction."
Mulhollan stressed that the rule can help improve patient care. "This not only prevents patients' benefits from being hijacked but also from having the wrong medical information from being placed in their record because of fraudulent activity, which creates a clinical risk."
The TMA's Beatty urged doctors to keep it simple and take advantage of a number of free resources from the FTC and organized medicine.
"Don't wait until the last minute," he said. "Make the investment so at least your staff are aware of the issue and you are in compliance on day one. Then it's one less issue to deal with."
The print version of this content appeared in the May 25, 2009 issue of American Medical News.
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Posted in Uncategorized at 1:01 am by amit
Washington -- A diverse and influential group of organizations representing physicians, hospitals, insurers, drug manufacturers, medical device companies and service workers pledged to work together to reduce national health care spending by $2 trillion or more over the next decade in an effort to enable health system reform.
The groups met with President Obama May 11 to say they would do their part to reduce the annual rate of health spending growth by 1.5% per year over the next 10 years. The organizations included the Advanced Medical Technology Assn., the American Hospital Assn., the American Medical Association, America's Health Insurance Plans, the Pharmaceutical Research and Manufacturers of America, and the Service Employees International Union.
If successful, the effort would not decrease total spending on health care but would significantly reduce the rate of spending growth. Government actuaries have estimated that such growth otherwise would average 6.2% per year over the next decade.
After meeting with the groups privately, Obama described the announcement as a "watershed event" in the health system reform debate. "Their efforts will help us take the next and most important step -- comprehensive health care reform."
The groups involved have not always agreed with each other or with those in government on the need to overhaul the system, Obama noted. "In fact, some of these groups were among the strongest critics of past plans for comprehensive reform."
Some experts said the development bodes well for the success of reform this year. "If the savings described today truly occur, this may be one of the most significant developments in promoting meaningful health care reform," said Ron Pollack, executive director of the health consumers group Families USA.
A May 11 letter to the president said the organizations are developing consensus proposals that would achieve the savings. The initial descriptions lack many details. Instead, they include broad cost-saving concepts such as administrative simplification, reducing over- and underutilization of services, care coordination and health information technology.
The groups said they would release more details within weeks. The White House has given them a deadline of early June to submit proposals.
But some skeptics weren't waiting that long to dismiss the announcement as largely inconsequential. "Today's announcement promises savings with no concrete plan to achieve them and no enforcement mechanism if they don't," said House Minority Leader John Boehner (R, Ohio).
Boehner noted that pledges of future cost savings do nothing to reduce the budgetary costs to Congress of overhauling the system. Obama still has not explained how he will pay for his multitrillion-dollar plan, he said.
The half-dozen organizations acknowledged that the promised spending reductions were voluntary for now, but they indicated that several of the measures could be written into law. Despite the $2 trillion goal, the groups said they were confident none of their members, including physicians and other medical professionals, would need to swallow major pay cuts to make the goal a reality.
Groups keeping own priorities
The organizations that made the savings pledge made it clear they would continue to promote their own reform policy goals despite the common effort. AHIP, for instance, continues to oppose a White House proposal to offer a government-run public health plan to compete with private insurers, but SEIU supports the move.
In some cases, the organizations connected the savings goals directly to their own priorities.
"As we mentioned to the president, if we can have additional liability protection ... then we can achieve even more spending curbs and a reduction in cost," said AMA President-elect J. James Rohack, MD.
Physicians often want to help reduce over-utilization but find it difficult, Dr. Rohack said. As a cardiologist, for instance, he said some of the screenings he orders for patients are likely unnecessary, but he feels compelled to prescribe them because of the liability risk.
But some observers said the development simply showed health industry stakeholders attempting to gain more leverage in the reform debate by making vague commitments that are relatively easy to offer. A truly substantial shift by the groups would have taken more time and involved more major policy changes by these membership organizations than was apparent in this case, according to Joseph Antos, a health care scholar at the conservative American Enterprise Institute.
The groups' statement that they are still working on long-term plans for ideas that in some cases date back decades instills discouragement rather than hope, Antos said. "What it says is that all the ideas that all of us hope will work still aren't ready for prime time, and they're not going to be ready for years to come."
Public plan in play
Others saw the move primarily as a bid by the health insurance industry to gain negotiating room for mounting a stronger opposition to a public plan insurance option, though the organizations insist that issue never came up in their talks.
"This commitment to cost-cutting is a good-faith gesture by the health care industry, but it does not mitigate the need for a public plan option in the upcoming reform bill," said Sen. Charles Schumer (D, N.Y.). Conversely, Sen. Orrin Hatch (R, Utah) has said Democrats are using the threat of a public plan to force concessions from the private insurance industry.
Members of Congress have begun taking sides on the public plan option. Senate Finance Committee Chair Max Baucus (D, Mont.) and the panel's highest-ranking Republican Charles Grassley (Iowa) on May 11 released the second in a series of three policy-options papers that includes three ideas on how to create a public health insurance plan.
But many Republicans oppose the idea, because they say the government won't be able to create a public health plan that allows private plans to compete with it on a level playing field. Baucus said in early May that the idea was under fire but not dead. "The public plan may be on the side of the table, but it's on the table."
Physician organizations largely have withheld judgment on the concept. AMA President Nancy H. Nielsen, MD, PhD, said the insurance industry needs reforming. But she added that "there has been a long history of public programs that are not adequately funded, resulting in cuts to those who provide health care and access challenges for those who get care through these programs."
The American Academy of Family Physicians board of directors voted in April to support the public plan option, said AAFP President Ted Epperly, MD. Primary care fees actually may rise if it is adopted, he said.
The print version of this content appeared in the May 25, 2009 issue of American Medical News.
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Posted in Uncategorized at 1:01 am by amit
Washington -- Preventing Medicare pay cuts for physicians and finding funding for additional rate updates could prove easier if Congress follows a health budget released May 7 by President Obama.
The president's fiscal 2010 budget for the Dept. of Health & Human Services totals $879 billion in outlays, an increase of $63 billion over fiscal 2009. Although it calls for additional spending in several areas, it also proposes saving hundreds of billions of dollars from Medicare so the money can be spent elsewhere, possibly on boosting physician pay or other reforms.
In a shift from the previous administration, the budget also says the department will look into the feasibility and legality of removing the costs of physician-administered drugs from the calculation of the Medicare physician pay formula.
The American Medical Association and other physician organizations have maintained that these unrelated drug costs artificially skew the results, causing physicians to exceed spending limits and making the threat of cuts to doctors much larger. The organizations have said Medicare has the authority to take Part B drugs out of the equation retroactively at any time, an administrative move that would free up billions of dollars for physician pay and reduce the size of the upcoming cuts that Congress would need to address.
But the Bush administration steadfastly refused to make the administrative change, insisting that it did not have the statutory authority under Medicare law to make such a move. Obama says in his HHS budget that his administration at least will look into the option.
"We take it as a very positive sign that President Obama's budget says that the new administration will explore this issue," said AMA President-elect J. James Rohack, MD. "The AMA will work with the administration to expedite the removal of drugs from the formula, as this will significantly reduce the overall legislative cost of permanently reforming the Medicare physician payment update system."
But although the budgetary cost to Congress of tackling physician rate cuts would become smaller under such a move, the billions of dollars that would be shifted into physician pay by the administrative change would run up federal deficit spending. GOP lawmakers and other budgetary hawks on Capitol Hill have announced that they will oppose new health care spending that does not have the appropriate funding offsets.
Spending and saving
To promote more honest budgeting, the Obama administration is adjusting its Medicare budget estimates by $311.1 billion over 10 years to reflect its best estimate of how much more Congress will spend on boosting physician pay. That figure is based on the freezes and modest increases Congress has approved in recent years.
Obama has said he supports fixing the Medicare physician payment system. In the fiscal 2010 budget outline he introduced in late February, he said Congress should assume that fixing the sustainable growth rate formula outright would cost $330 billion over the decade.
The total White House fiscal 2010 budget for the Centers for Medicare & Medicaid Services is $758.9 billion, an increase of $56.3 billion over the fiscal 2009 level.
Despite the increase, Obama is calling on Congress to capture hundreds of billions in savings from Medicare.
The HHS budget includes language on establishing a competitive bidding system for Medicare Advantage that would save nearly $180 billion over 10 years.
HHS also has announced its intent to increase funding for Medicare fraud and abuse control.
"We estimate that for every $1 we spend to stop fraud in the system, we save $1.55," said HHS Secretary Kathleen Sebelius. "The president's budget lays out funding for anti-fraud efforts over five years that we estimate could save $2.7 billion."
The administration's Medicaid budget also calls for producing about $8.8 billion in savings over five years that would be achieved largely by mandating increased Medicaid drug rebates from manufacturers and managed care plans.
Altogether, the budget calls for Medicare and Medicaid savings totaling $309.1 billion over 10 years that would be used to finance a portion of a health reform reserve fund.
Curtailing physician-owned hospitals
The president's proposed HHS budget also calls on Congress to prohibit new physician-owned hospitals from seeking payment for services rendered to beneficiaries who are referred to the facility by a physician with a financial interest in the hospital.
If Congress follows the White House lead, existing physician-owned hospitals that practice such self-referral would be grandfathered in if they meet certain criteria, but they would be prohibited from expanding.
The AMA supports physician-owned hospitals and has strongly resisted attempts to curtail their growth.
But community hospital supporters and some in Congress argue that such facilities cherry-pick the healthiest, most profitable patients and leave the general facilities to shoulder the burden of costlier cases and charity care.
Some key lawmakers in Congress have been attempting for years to ban specialty hospitals or at least prevent new facilities from opening their doors.
The print version of this content appeared in the May 25, 2009 issue of American Medical News.
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Posted in Uncategorized at 1:01 am by amit
Washington -- President Obama's pick to serve as the next commissioner of the Food and Drug Administration defended a plan to have the FDA regulate tobacco products and pledged a vigorous response to the ongoing outbreak of influenza A(H1N1) before a largely supportive Senate committee in early May.
Senators from both parties said they would back FDA Commissioner-designate Margaret A. Hamburg, MD, currently a senior scientist with the Nuclear Threat Initiative in Washington, D.C. At this article's deadline, her nomination was expected to be approved by the committee -- and subsequently the full Senate -- within weeks. "I just wanted to let you know that I support you and I intend to help you," Sen. Orrin Hatch (R, Utah) said to Dr. Hamburg during her May 7 nomination hearing before the Senate Health, Education, Labor and Pensions Committee.
Dr. Hamburg addressed what is expected to be one of the more controversial issues that would be on her plate as FDA chief, responding that she supports a proposed change in law to give the agency regulatory authority over tobacco products. She said the health burden that smoking places on the nation as well as the unique characteristics of tobacco products make the move imperative.
"This is a critical moment, I think, to take a more aggressive look at how we regulate tobacco products ... and to reduce the risks of tobacco products to the American people," Dr. Hamburg said.
"I think the FDA is the appropriate agency to regulate tobacco. They have the scientific expertise," she added.
But not all committee members agreed.
"FDA resources are already stretched too thin," said Sen. Mike Enzi (R, Wyo.). "I have serious concerns about adding tobacco to the list of products the agency must regulate." Other lawmakers have questioned the logic of having an agency devoted to protecting the public health overseeing a product that they say can never be safe.
Still, Congress is moving forward. The House on April 2 passed the Family Smoking Prevention and Tobacco Control Act by a 298-112 vote. The Senate was expected to follow suit soon after the Memorial Day congressional recess.
The measure would grant the FDA the ability to regulate the manufacture, marketing and sale of tobacco products, a move cheered by numerous health care groups. The measure, however, would not allow the FDA to ban tobacco products outright or to eliminate nicotine.
The bill would codify a 1996 rule under which the FDA stated its authority to regulate cigarettes and smokeless tobacco products. The rule was struck down in 2000 when the U.S. Supreme Court in FDA v. Brown & Williamson Tobacco Corp. ruled that the agency did not have the authority to enforce the regulation.
American Medical Association President Nancy H. Nielsen, MD, PhD, said the legislation is "critical to combat smoking-related diseases and help get cigarettes out of the hands of children."
Handling the influenza scare
One of the first matters Dr. Hamburg addressed before the HELP committee was how she would handle the recent flu outbreak. Her confirmation hearing was moved up by nearly a week primarily because of concerns about the nation's response.
"If confirmed, I will review FDA's work on the H1N1 influenza situation to determine if there are additional steps FDA can take to make safe and effective medical products and laboratory tests available," she said. Senators noted Dr. Hamburg's past experience with handling infectious diseases, particularly in her role as New York City's health commissioner, where she worked on the development of a rapid-response model to battle an epidemic of drug-resistant tuberculosis.
"Dr. Hamburg is widely respected for her expertise in community health, biodefense, and nuclear, biological and chemical preparedness," said Sen. Edward Kennedy, (D, Mass.), chair of the HELP committee. "Her expertise is valuable for problems we now face, such as combating food-borne illness, cooperating with other agencies to address the new flu outbreak and drug-resistant diseases, and protecting our food and drug supplies."
The print version of this content appeared in the May 25, 2009 issue of American Medical News.
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05.07.09
Posted in Uncategorized at 1:01 am by amit
Washington -- The Senate Finance Committee, whose leaders appear to have taken the helm in the health system reform debate, started a round of public talks with health organizations in a run-up to an aggressive reform timetable.
National reform legislation in the Senate will likely show the influences of an April 21 roundtable discussion. It focused largely on how a rural health system improved care and lowered costs for chronically ill patients, how patient needs and incentives should drive reform, and whether a federal health agency should have more authority to innovate.
The Senate Finance Committee roundtable on improving care and reducing costs was the first of three on major health reform topics. Two more are scheduled for May. Committee members in the days following each discussion will review and comment on each corresponding piece of the legislation before the final package is unveiled publicly for a formal committee markup and vote, possibly as early as June.
Senate Finance Committee Chair Max Baucus (D, Mont.) said it's time to move. "If we don't act now -- that is this year -- the consequences will be dire."
Sen. Charles Grassley (Iowa), the committee's highest-ranking Republican, said tackling health care, which accounts for 16% of the nation's economy, is daunting. "This is the toughest and most needed issue that Sen. Baucus and I have ever been involved in."
The Finance panel and the Senate Health, Education, Labor and Pensions Committee began conferring with health care organization leaders about legislation last year. House committee chairs began holding hearings more recently, and Republican groups in the House also are working on their own proposals. House and Senate committee chairs have agreed to try aiming for floor votes on reform legislation before the August congressional recess.
The Geisinger way
The Senate Finance roundtable on April 21 included 13 participants representing health plans, physician organizations, consumer advocates, auditors, researchers and others.
But committee members spent a significant part of the discussion asking Geisinger Health System President and CEO Glenn Steele Jr., MD, PhD, about replicating on a national scale the organization's care coordination for chronically ill patients and other innovations.
Health care costs account for 16% of the nation's economy.
The Pennsylvania-based health care system is a mostly rural network of physicians, nurses and hospitals combined with a health plan serving about 30% of its patients. Dr. Steele said Geisinger asked its health professionals to follow evidence-based guidelines or to develop consensus-based care standards for prevalent chronic diseases, such as diabetes, coronary artery disease, congestive heart failure and kidney disease. It also targeted the sickest patients in its health plan and assigned additional nurses to assist physicians with care coordination.
"What we've shown is that when you increase quality for these groups of high-utilizing patients, you're also decreasing costs," Dr. Steele said. A number of Geisinger's practice sites saw a 50% or higher decrease in hospitalizations in one year after the project launched about five years ago, he said. Many patients had not been taking their prescribed medications at the right dosage or frequency.
Sen. Debbie Stabenow (D, Mich.) asked about the advantages of having an integrated health system. "That is a different delivery model than we have in a lot of areas," she said. Most patients still receive care in practices with five or fewer physicians, noted participant John Tooker, MD, American College of Physicians executive vice president and CEO.
Dr. Steele said having its own health plan allowed Geisinger financially to reward physicians and nurses who improved patient care. Also, most of the system's patients live in rural areas and do not change residences often. This helps the health system track the outcomes of its care over years, not just weeks or months, he said.
Geisinger's health information technology network is another key factor, Dr. Steele said.
An electronic health record system implemented 14 years ago allows patients to see lab and radiology results, request prescription refills, e-mail questions to doctors and nurses, and schedule their own appointments. "We couldn't do it without [health IT] throughout our entire geography. It would be impossible because of the physical distances," he said.
Centers for innovation?
Baucus asked Dr. Steele how he would apply the lessons he learned at Geisinger on a national basis. "The first thing I would do is to redesign" the Centers for Medicare & Medicaid Services, Dr. Steele said. "I think CMS needs to be an engine of innovation, not a self-defined bureaucracy."
The Geisinger chief said Congress should start by giving CMS more leeway to launch demonstration projects quickly that are focused on Medicare patients who cost the most and receive the least-coordinated care. That would entail giving CMS clear goals for the patients' health and creating a backup reform plan that serves as a stick to motivate the agency to achieve its primary goals. The project could begin with a few million patients and expand to the entire Medicare population, he said.
Most patients receive care from practices with 5 or fewer physicians.
Dr. Steele said CMS must be allowed to adjust the pilot project as needed. "A lot of what we did was accomplished because we were able to change on the fly."
Sen. Jeff Bingaman (D, N.M.) asked the attendees if CMS could tackle such an undertaking. Mark McClellan, MD, PhD, a former CMS administrator, said the agency would need a bigger budget and more authority. "Medicare, the way it is managed now, does not leave a lot of room for discretion in implementing the kinds of reforms we're talking about today."
Glenn Hackbarth, chair of the Medicare Payment Advisory Commission, suggested that Medicare could partner with private payers to work on incentives that reward effective care integration by health professionals.
Grassley asked if national health system reform required additional spending. Other Republican senators questioned the need for new money, considering the billions they said could be saved by reducing fraud and unnecessary care.
Sen. John Ensign (R, Nev.) said Medicare reform also should give beneficiaries financial incentives to shop for the best deal in health care. This could happen if electronic health records delivered health professionals' cost and outcome information to patients, he said. "We don't need more money in the system; we need to spend our money more properly and have the incentives."
Hackbarth said national health spending variations could be leveled by focusing on the highest-spending areas while understanding that "there's not one single right way to deliver efficient health care."
The discussion seemed to resonate with Baucus, who mentioned at a breakfast with reporters days later the possibility of reforming CMS.
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