Secure Transfer System »     Client Portal Access »

Posts in the ‘Industry Updates’ Category

The 2012 Physician Fee Schedule: Here We Go Again

Posted by J. Paul Spencer, CPC, CPC-H in Industry Updates

As an overfed American with a penchant for sandwiches, it grieves me to report that my current weight stands at 217 pounds. To measure it against random things in my immediate universe, this equates to roughly 79 unsweetened iced teas from Speedway or the contents of just over 694 bottles of Tabasco.

If I reduced my current girth footprint by 27.4%, my weight would be roughly 158 pounds. I’d also be 15 years old, pummeled with acne and at the mercy of the world of 1981, and I promised myself that I’d do my best to avoid the music of Juice Newton for the rest of my life (and no, I’m not providing a hyperlink; it was that bad).

It is with these thoughts in mind that I begin the annual November discussion of physician fee schedule cuts to the Medicare program.

The 2012 Physician Fee Schedule Final Rule was released this week. The size of the cut, representative of the can that has been kicked down the road for over ten years, now stands at 27.4%. Medicare tells us that this is good news, because due to unexpected savings this year, the original scheduled cut of 29.5% has fallen to only the stated percentage.  

If this were any other year, I would shrug this off. We think we all know the drill by now. Every November, just in time for the coming holiday season, we get the fire-and-brimstone treatment with a threatened cut to the fee schedule, and at the last minute (sometimes a few moments after), everything  goes back to normal. Maybe, if we’re lucky, we actually get a few percentage points of a payment increase.

One look at any believable information source will tell you that this is not your typical year. 

We exist in a world where politicians around the globe have developed an unhealthy fetish for economic austerity. Great Britain was the first country up to the plate, slashing government programs like Freddy Krueger, only to find out too late what any reputable economist could have told you from the beginning, which is that slashing spending also slashes growth to near-zero. At this moment, Greece straddles the precipice between being a flat-broke member of the European Union, or a flat-broke country descending into anarchy that threatens to take the entire EU banking structure down with it. Other European nations are slowly lurching towards the same fate.

We’ve seen unprecedented allegiance towards austerity in this country this year in a fashion that can only be described as sociopathic. Rock bottom was reached when Eric Cantor, the 2nd-in-command in the House of Representatives, refused to provide emergency aid to his own Virginia congressional district when it was hit with an earthquake without equal cuts coming from other parts of the federal budget.

With this type of attitude at the fore, I have little hope of a last-minute fix to the fee schedule this year. The very idea of across-the-aisle compromise has come to an end in this country. Physicians, a group that used to have a seat at the lobbying table, will be left out in the cold in favor of industries who write bigger checks for a seat at the table.

I have definitive reasons for not wanting to weigh 158 pounds. I could stand to lose a little weight, but losing 27.4% of me would be counter-intuitive to existing in the modern world. Those of us faced with the realities of physician reimbursement know full well that these types of cuts from the Medicare portion of the physician bottom line could be lethal. Reductions of this magnitude almost certainly insures that care will be deferred for the portion of the population that, with regard to their health, possesses the narrowest margin for error.

However, the current political landscape doesn’t bode well for avoiding this fate. At the same time that the cuts are scheduled to take place, Presidential primaries begin, accompanied by chest-beating about who can cut the national debt by a wider margin. Add to the mix the European Union tanking and police in riot gear responding to people in the streets of our country demanding balance and fairness to our economic system and you have a recipe not just for a health care meltdown, but a societal one. The principals in this debate are digging in their heels and showing no signs of compromise. With all of the hand-wringing, no one is talking about eliminating the Sustainable Growth Rate, which is the root cause of this problem.  

I’d tell the physician reading this to buy popcorn and watch the self-defeating circus from the sidelines, but perhaps packets of ramen noodles would be a better, cheaper alternative. If needed, I’ll provide the Tabasco.

Tags: , , , , , , ,
November 4th, 2011 | No Comments »

Health Care Reform: Chaos From Order

Posted by J. Paul Spencer, CPC, CPC-H in Industry Updates

I had an interesting visit in my cubicle this week. My CEO stopped into my occupational man-cave to tell me that my blog posting content was good lately. He’s a very busy man, so I appreciated the visit and the input.

There was one part that I left out when discussing this and other issues with him. There are some days when I really have a hard time trying to explain the ins and outs of the American health care system. There’s a part of me that believes that with regard to this topic, the ability to write about it is some type of penance for something I did in a past life. What sick and depraved part of my being keeps getting excited about attempting to explain chaos? I’d rather talk about things that make sense to me, such as the purity of the perfect sandwich, economy cars or ice hockey. Instead, I am entrusted with medical delivery in the United States.

This past week, it became clear that this chaos is about to get worse.

On the legal front, The Supreme Court, which at one time in the distant past was concerned much less about the rights of corporations, announced that it will hear legal challenges to the Affordable Care Act in the opening weeks of November. The thrust of the challenge goes to the Act’s mandate to individuals to purchase health insurance coverage. The ruling, which will more than likely occur in the Spring (just in time to become a Presidential campaign issue) should be interesting. The Court, in its current ideological construct, is pro-business and anti-government. So, how do they rule against a government mandate when the biggest financial beneficiary of the Act is the insurance industry, which we can all agree represents a big business? Get ready for some of the most twisted logic ever committed to paper when the Court releases its ruling. I recommend some type of release valve be installed in your skull prior to that time to prevent the sudden explosion of your head.

PPACA’s life span is a good lead-in topic to the next bit of news that’s slowly coming forth. In the current budget crunch, individual states are beginning to restrict the number of total days per year that Medicaid recipients can be hospitalized. The latest state to vote for such a restriction is Hawaii, which beginning in April 2012 will restrict the number of days to 10. This is the lowest number yet enacted on the state level.

Here’s where policies like this lead. The sickest Medicaid patients, who also double as the poorest residents of the states in which there is a cap, are billed for the unpaid portion of their hospital stay. These bills goes unpaid because the problem isn’t solved by the patients cancelling their country club memberships or selling their cars, as they don’t possess these things. At the end of the process, the hospital eats the bill because they are in the business of admitting people to their facilities who are sick. Hospitals will turn around and shift costs to private health plans, which in turn pass off the costs to insured patients in the form of premium increases. Depending on the dent the new premium places on the healthy privately insured patient, the healthy person may decide to let his or her coverage lapse, which increases the premiums that much more for those who keep their coverage. If the hospital can’t shift the costs, especially a hospital in a rural area, the hospital faces closure.

Remember that at the root of PPACA is an expansion of state Medicaid programs to a higher percentage of the population. On the brink of millions more qualifying for this type of coverage, Medicaid will stop paying for your care after a pre-determined utilization threshold is reached. You barely qualified for your new coverage based on economic factors and now, your coverage stops. This Bill’s for You!

I’m what I would consider a fairly sentient being. I can make sense out of virtually anything. If I can’t make sense of something, such as artichokes, speed limits or baseball’s balk rule, I’ll at least make the attempt. With regard to America’s health care system, I’ve come to a decision. If the world is ever invaded by aliens, in the absence of enough advanced weaponry, I’ll fight off the invasion by explaining the American health care system to them in detail. All it really takes to destroy someone is to introduce an idea too complex to be comprehended and then watch their will and spirit collapse from within in an attempt to understand. Our health care system provides that opportunity amply.

Now, where did I put that skull valve……

Tags: , , , , , ,
October 28th, 2011 | No Comments »

CMS Clarifies Predictive Modeling

Posted by J. Paul Spencer, CPC, CPC-H in Industry Updates

I’d like to start this post today by stating categorically that it is a frustrating experience when one types out an entire blog post, follows that by clicking the “Save Draft” button, and in an instant watches a few hours of work disappear. Such is my current predicament. When you read everything below, bear in mind that this is my second pass at today’s topic, much like any clone, there will be things that are just not right, or that represent a horrible attempt at finishing something hastily. Setting this aside, I hope that you find the following information useful.

While I was out of the office for a few days, I received an e-mail from CMS about a topic I covered only briefly in the past. With a special article serving as clarification, CMS went into further details about predictive modeling techniques currently being utilized to reduce the payment of fraudulent claims, and what this will mean for providers, their patients and networks.

Let me quickly type in an overview of what this means before Word Press explodes.

All claims from June 30th, 2011 and after are being fed into CMS’ predictive modeling technology. The information from the claims is then diced, sliced and analyzed Jetsons-style with regard to provider and patient utilization. This leads to the building of profiles not only of providers, but patients as well.

After all of these high-speed calculations comes the assigning of risk scores based on the data collected. Those entities coming up with higher risk scores will be subject to payment delays, followed by a site visit, reviews of claim histories and interviews by CMS analysts at its discretion. If, after analyst intervention and inquisition, the billing is found to be “innocuous” (you know, like a quilting bee or the Lions Club), that outcome is recorded into the predictive modeling system and the payment for the claim(s) in question is released as usual. 

Now the rough part.

If an analyst finds indications of the not-so-innocuous (you know, like Tony Soprano or Dr. Jekyll), these cases will be referred to CMS’ Center for Program Integrity, the MAC involved and the ZPIC contractor in that particular geographic zone. The result could be targeted denials, revocation of billing privileges, and that classic cinema verite production entitled “A Raid”, featuring veteran co-stars Records Seizure, Perp Walk & Civil Penalty.

The main thrust of this new method is the fact that false claims investigations are no longer a guess, or reliant on someone blowing the whistle on an illegal practice. The government is now using the same types of pre-screening methods that used to be reserved for banks and credit card companies to catch the cheaters in the Medicare program. As a taxpayer, I would say this is about 45 years overdue. As a physician advocate, what I do for a living with regard to practice analytics and documentation review just became very interesting.

Tags: , , , , ,
October 21st, 2011 | 1 Comment »

The Nervous Animals of ICD-10

Posted by J. Paul Spencer, CPC, CPC-H in Industry Updates

It was roughly 9 years ago this week that my wife Leslie and I moved to Milwaukee from suburban Philadelphia. We had experienced some tough times back on the East Coast, and our final night there was no exception. We ended up loading our moving truck, with the help of two friends, as the leading edge of Hurricane Isidore passed through the area. Nothing says “Let’s leave here and never come back!” better than having to pack a moving truck while it’s raining horizontally.

Severe meteorological events, in the absence of a TV or a radio, are most often prefaced by animals acting strangely, whether it be either zoo animals in a cage pacing back and forth at a quickened pace or birds suddenly taking flight en masse away from the coming cataclysm. We have one such storm being tracked in the world of health care, that being the implementation of ICD-10 on October 1st, 2013.

I can honestly state that over these past two weeks, I for the first time noticed the animals of our industry beginning to shuffle nervously for the impending arrival of ICD-10. When I first became a certified coder in 1998, I was told that ICD-10 was right around the corner, with the first implementation date being the year 2000. When ICD-10 finally sees the light of day as our disease reporting system, 15 years will have passed from those first pronouncements.

The biggest lesson I learned between those early, naive days and the release of the ICD-10 final rule on January 16, 2009 was that the chances of any major health care change coming to fruition can be measured directly against the amount of lobbying dollars the insurance industry spends in order to insure that the change never comes to pass. It was well known that the bigger payers, after over a decade of mergers and acquisitions, were in no mood to spend the money necessary to condense all of the claims payment systems they inherited into one better system utilizing the updated coding standard. When ICD-9 became severely outdated for our providers, the American Hospital Association stepped in and took up the cause, which led all of us to where we are.

Most people outside of the industry are unaware of how ICD-10 will affect health care when it hits. At the symposium hosted by the Wisconsin Medical Society that I attended earlier this week, a number of attendees were talking about this article from the Wall Street Journal. While this could have worked to warn the general public about expected claims delays and drops in productivity that have been experienced in other countries that have undergone implementation, it instead decided to point out funny examples contained in the code set. When I think of improved disease and symtomology reporting, I think about stamping out major epidemics before they happen, rather than being flippant about the fact that we’ll be able to accurately report when someone injures themselves walking into a lamppost. What would we do without the press?

The countdown clock for ICD-10 now stands at 738 days. As that number continues to deflate, expect the lower order animals in our industry to continue their wringing of hands, pacing back and forth and stocking their figurative basements with cans of bargain soup and bottles of water. For the rest of us, we have known for years now that “duck-and-cover” is not a useful strategy when it comes to ICD-10. This new code set isn’t going away, it isn’t going to be delayed any longer and it will not make anyone’s life easier in the short term.

Having stated that, there’s no reason to retire in fear, and the conversion need not be as painful as envisioned. Begin planning now to avoid the looting and car crashes later. Start with a pre-emptive strike on your EHR vendor by putting them through your own form of the Spanish Inquistion. Ask them if they are preparing for ICD-10 and about any planned upgrades. Scour all of your contracts for any mention of ICD-10. If it isn’t there, negotiate favorable terms to add it, and if it is there, find out what it means to your organization.

Like most everything else in this country, it is difficult to drag a large swath of our population into the modern age. This one can’t be accomplished by fear-mongering and snarky jokes. Anyone weathering the oncoming storm will succeed with the only thing that ever truly does, which is work.

Tags: , , ,
September 23rd, 2011 | 1 Comment »

The Hidden Disadvantages of Buying on Faith

Posted by J. Paul Spencer, CPC, CPC-H in Industry Updates

My house is not usually stocked with junk food, despite the fact that it tends to find me. In those many moments when snack food isn’t available, I tend to reach for the nearest box of cereal.

There has always been one thing that annoys me about breakfast cereals in this country. I have never possessed a box of cereal that contained all perfect specimens. The best example I can give is your basic box of Rice Krispies. Among all of the perfectly toasted grains of dried rice making noise in my bowl, I inevitably find that one black piece of rice that disguised itself among hundreds of other grains poured into my bowl. This outlier grain of rice is always found after I pour the milk in the bowl, which then leads to me spending five minutes trying to fish it out of my bowl before I accidentally eat it. To this day, I have no idea of the consequences are of consuming the black Rice Krispy, and I don’t want to know.

Each one of us, no matter what the product, is susceptible to attractive packaging. The picture of the cereal on the box, strawberries happily floating on top like little red clouds, always looks good, and let’s face it; if the house is out of cereal, you’re going to buy the box. It’s only later that your frustration rears its ugly head when the myth of the packaging is exposed.

It is on this final point that I begin today’s discussion topic; physician alignment with hospitals.

In the lead-up to ACO formation, hospitals are currently on a physician buying spree that would make a sailor on shore leave blush. In a recent research paper by Thomson Reuters, 44 hospital CEOs indicated that physician alignment was an issue of increased focus. If we pair that with another report from Merritt Hawkins stating that 76% of all physician openings offer a signing bonus, and the conclusion can be made that now is a very good time to be a physician looking for employment by a hospital.

Yet as I examine the issue further, there is one critical component missing, that being the due diligence required to determine whether the physician in question is a compliance nightmare waiting to happen.

In the current audit environment, most hospital systems are just beginning to get their arms around the RAC process for facility services. Because the audit entities have yet to expand into physician services, hospitals with large physician populations haven’t focused on the risks presented by the billing practices of doctors. Into this environment comes recently-acquired physicians and their accessory baggage. They look great, what with their shimmering CVs and smart ties, but it’s what you can’t see (or what is not volunteered) that poses the greatest risk.

If a newly-acquired physician comes to your organization either as an outlier based on billing, a poor documenter or someone lacking familiarity with your chosen electronic medical record, he or she can pose an immediate risk to the entire system.

Thankfully, one area where I spend a great deal of my time is in the area of practice analytics. The operative principals are available to determine the risk a physician poses to a facility, and it can be done in a manner that is time-sensitive prior to acquisition. It is a clear choice between paying a little bit now, and paying a lot later. To rephrase, are you buying the Rice Krispies because of the package and trusting that the alluring box contains cereal without flaws? If so, get your spoon ready, as black Rice Krispy fishing isn’t as easy as it appears.

Tags: , , , , ,
September 9th, 2011 | 1 Comment »

One Service, One Payment: NOW They Tell Us…..

Posted by J. Paul Spencer, CPC, CPC-H in Industry Updates

In the human experience, there is an overarching idea that controls all of our thought processes known as “the common good”. As I tumble blindly down the hill of degeneration known as Growing Older, I’ve learned that “the common good” means vastly different things to different people, but one thing all of the divergent ideas have in common is the idea of personal sacrifice for improvement of the whole. Whether it is a farming commune, a church community or a governmental taxation system, personal sacrifice is is seen as the key ingredient on a promise of future gains, either in healthy crops, saved souls or roads without potholes.

It is with this idea in mind that I reviewed the latest CMS payment initiative, which was released on August 23rd. Entitled the Bundled Payments for Care Improvement Initiative, it offers four ways for caregivers to accept one bundled payment for an episode of care as a dangling carrot aimed at better care coordination and reduction of expenses. 

While there are four different payment models under the plan, I offer an illustrative example. A patient is in need of a hip replacement. The medical providers who treat the patient voluntarily negotiate one bundled payment with Medicare, covering all providers and services for the hip replacement. Under all four of the models (three offering retrospective negotiation of bundled payment, and one prospective), it would be up to the providers to determine how the one bundled payment is distributed among all of the entities involved with the patient’s care.

At first glance, I see this as another attempt to clarify and strengthen the ACO model. Farther down in fine print lies an enormous caveat, as noted in a brief article by FierceHealthcare this week. CMS states that preference for entering into a bundled payment arrangement will be given to providers who have at least 50% of their caregivers meaningfully using an electronic medical record (EMR). GIven where most hospitals are in the constructing of their particular ACO, this initiative comes a bit late.

Across the country, we have hospitals who are purchasing physician practices in the lead-up to ACO creation. As I communicate with people in this field, I am struck by the lack of due diligence exhibited by hospitals in selecting providers to hire. Most hospitals have no concept of how versed these physicians are in the use of an EMR, the quality of the provider’s documentation in its current form, the provider’s established billing patterns or the compliance risk to the facility of bringing on a particular doctor under the umbrella of the hospital. With respect to the EMR, as I have covered in previous posts here and here, use of an EMR may not signal the end of all compliance troubles, but a rather complicated beginning.

With the Bundled Payment Initiative giving preference to treating entities with high Meaningful Use percentages, hospitals may be regretting purchasing practices in the absence of this information, but it need not be a deal breaker. ACOs, by their very design, encourage a collaborative effort in the delivery of health care services. This idea needs to be applied not just to the care itself, but intangibles at the root of that care, such as the compliant use of an EMR.

The general idea behind the ACO model is that of the best ideas for low-cost care rising to the top. There are many paths to achieving ”the common good”, with human interaction and shared sacrifice being of paramount importance to the process. While this latest initiative might have assisted hospitals at the beginning of ACO formation by exponential factors had it been released earlier, better late than never.

Tags: , , , ,
September 2nd, 2011 | No Comments »

Add Some Science To The Argument

Posted by J. Paul Spencer, CPC, CPC-H in Industry Updates

This week, in the course of my usual perusal of all things newsworthy, I couldn’t help noticing that this has been a big week for science. Two planets, one colder than the human body and one that is made completely out of diamonds, were discovered by astronomers. A study estimated that there are roughly 8.8 million species of organism on the planet, with only 25% having been discovered thus far. Finally, and unfortunately, most every television we turn on right now has at least one oceanographic map showing the path of Hurricane Irene, showing us meteorology in more immediate terms.

In contrast, a majority of the news that came out of the health care sector this week revolved not around medical discoveries, but finance, and not in a good way. My inbox was seasoned with stories of hospital layoffs and mergers between facilities due to financial necessity. This past Tuesday, CMS released yet another payment initiative, this time dealing with bundled payments for facilities and physicians for hospital cases based on conditions treated, with the payments being generous or penurious depending on outcomes and applications of previously agreed-upon standards of care.

I am struck by the appearance of the rest of the scientific world moving forward while the medical community in the United States is focused not on research, discovery or health innovation, but with how to control costs.

There is a cautionary tale in another science story that came forth this week. Perhaps no scientific story will be bigger in 2011 than the end of the Space Shuttle program. In the beginning of the program, the Space Shuttles dealt mostly with the placement of satellites in high Earth orbit. In later years, one of the main tasks of Shuttle missions was delivering supplies to the International Space Station (ISS).

When the final flight of the program concluded earlier this Summer, it was understood that the reason for the demise of the program was its ”extravagant” cost. We were also told that the ISS would be resupplied by ships from the Soyuz program in Russia, as well as Japan and private firms in the United States. We were also told that they could provide the service at a lower cost.

With all of these facts in tow, and seeing what the orthodoxy of getting everything cheaper has done to destroy American businesses in my lifetime, it was with very little surprise that I read the story of the first such post-Shuttle resupply ship being launched in Russia on Wednesday, and subsequently crashing in Siberia. Three tons of food, water and other supplies instantly vanished. Lest anyone think that this is an isolated incident, it’s worth noting that this is the fourth failed launch from the Russian space program in the past nine months.

We find ourselves at a similar crossroads with regard to our health care system. The forces focused on lowering costs are beginning to dominate the argument about what’s best for the system as a whole. Lost in all the hand-wringing about dollars and cents is forgetting about the core mission of the field of medicine, which is healing the sick while doing no harm.

The study and application of the fundamentals of medicine is, at its root, a purely scientific endeavor. It has been a common refrain from our medical community, in the face of nearly 40 years of insurance company battering, that defensive medicine is now the norm. This style of practice is not what they have been trained to apply. We have learned far too often in human history that science must possess, above all other things, precision. When this is sacrificed to save a few dollars, you get results such as the children of thalidomide, E. coli outbreaks from our food and supply rockets crashing in rural Asia.

The study of evolution is in large part a study of adaptation. Our health care system is beginning to adapt to a cheaper model, but more and more I suspect that the evolving organism resulting from cost-cutting orthodoxy may turn out to be one far more lethal than any we have seen before.

Tags: , , , ,
August 26th, 2011 | 2 Comments »

When Is A Business Model Not A Business Model?

Posted by J. Paul Spencer, CPC, CPC-H in Industry Updates

My wife is not a big fan of gambling. In the few instances during our nearly ten years together where we’ve found ourselves in a casino, we tend not to hang around long. We were in Vegas once and I dropped $60 on a particularly surly slot machine. What I wouldn’t give to have avoided that ten minutes of spousal rage.

When we think of gambling, we tend to think of smoke-filled dens of thick carpeting, thicker cigarette smoke and the thickest dreams of hitting it big. Yet gambling comes in many forms, such as driving a car at rush hour, eating a sandwich from 7-11 or sitting on a toilet seat in a truck stop.

Thanks to data from two recent independent reports, we can add running a medical provider organization to the list.

The first of these reports was released on Tuesday, when the American Medical Group Association (AMGA) detailed the ongoing struggle of physicians nationwide to develop a workable business model. The survey of medical group compensation and finances found that most provider organizations are operating at a loss. 

The section of the country where the group operated in 2010 went a long way in determining the average extent of losses. This ranges from organizations in the Western region of the country averaging a loss of -$27 per physician, to the Northern region of the country, where physicians are operating at a staggering yearly loss of $10,669 each. This was in spite of the fact that compensation increased roughly 2.4% across all specialties in 2010.

If the AMGA survey set the table, another survey from the Medicus Firm offered information that seemed to find at least some sources of the revenue problems faced by physicians. Medicus’ survey, found here, found that the average compensation of those surveyed was down .14% from 2009 to 2010. Sixty-six percent of physicians surveyed stated that they expect their income to either stay the same or decrease in 2011.

When physicians were asked what issue most limits their income, 30.2% selected reimbursement decreases, which far outpaced other factors such as payor mix, increases in overhead and patient volume.

We are in the beginning stages of what is expected to be a critical shortage of primary care physicians. When such a large swath of the established physician community objectively states that they don’t see their financial lot in life improving, that certainly works as a flare fired above the heads of potential medical students faced with a decision to take on ten years of college loans for an occupation where reimbursement has plateaued.

These and other surveys are also taking note of the fact that hospital affiliation doesn’t equate to a better financial outcome. My inbox has been littered lately with stories of hospital systems trimming payroll by removing employees at the bottom of the ladder. This may very well be a side effect of the pre-ACO physician hiring binge. Odds are strong that physicians that have already affiliated with hospital systems will see their salaries flatline as the realization hits home that someone needs to absorb practice expense.

The bottom line is that between declining reimbursement and the looming threat of more of the same under PPACA, the incentives to remain part of the medical profession are disappearing. Physicians are told by a new era of hard line legislators and an entrenched insurance industry that they must accept someone else’s business model and deal with it. In order to build a working model, you have to have a reasonable expectation of revenue, which, given the insurance industry’s penchant for non-compliance with their own fee schedules, is impossible.

Interestingly, in the Medicus survey, less than 5% of physicians overall stated that the concierge practice appeals to them most, with the majority of physicians continuing to prefer the familiarity of a single specialty practice. Sometimes, the worst kind of gambling happens not in a casino, but in the place that is most familiar to you, when you simply decide to do nothing in the hope that things improve. In the immortal words of Kevin Bacon in that cinematic classic Animal House, as he absorbs hits from a wooden paddle to his gluteus maximus, “Thank you sir, may I have another!”.

Tags: , , , , ,
August 19th, 2011 | No Comments »

The Electric Kool-Aid Grandma Test

Posted by J. Paul Spencer, CPC, CPC-H in Industry Updates

One of the choices I have made in my life is to sport long hair. This is mainly to deflect attention from my enormous ears. Whenever you hear of a satellite or other space-based device crashing to Earth, it was more than likely caused by me turning my head to the left, causing all navigation systems to fail.

There are drawbacks to being a man with long hair, such as intense, knee-jerk police scrutiny for all crimes committed in the last 20 minutes and acquaintances eschewing the usual greeting of “Hello” by replacing it with “Dude!”. These minor inconveniences pale in comparison to what people believe to be my very intimate knowledge of illegal drugs, which is in actuality nil. I like after-hours beer. Beer has been legal in the United States since 1933. I tell friends that perhaps, when I’m retired and my social and occupational responsibilities become greatly reduced due to the limitations of  advanced age, I’ll revisit this stance.

However, if an OIG report that was released this week is any indication, that choice may not be my own in my twilight years.

When the OIG released their annual work plan for 2011 back in September, one issue related to nursing homes caught my eye. The OIG planned to look at the usage of what were termed “atypical anti-psychotic drugs” for nursing home patients. The definition of “atypical” in this case is not so much applied to the drug that is being administered, but rather the patients and conditions for which the drug is being dispensed. 

There are very strict protocols for anti-psychotic drug regimens for nursing home residents. Only in cases demonstrating an active diagnosis of schizophrenia and/or bipolar disorder can these drugs be utilized, and in those cases only under strict protocols defined by CMS. In all, eight of these types of drugs are approved for use in nursing homes. Since 2006, these drugs have been accompanied with an FDA warning that the drugs pose a risk of death to elderly patients already diagnosed with dementia.

The investigation has as its genesis a $98 million settlement against a large long term care pharmacy provider for receiving kickbacks from one of the eight drugs’ manufacturers to recommend their drug over the others. As the smoke cleared from this settlement, Senator Charles Grassley, the ranking Republican member of the Senate Finance Committee, requested that the OIG look into the use of these drugs in the nursing home setting. While his interest was strictly financial, the results of the investigation of claims for the drugs from the first six months of 2007 should raise eyebrows.

The OIG found that 51% of all claims for these types of drugs were erroneous, leading to overpayments to the facilities totalling $116 million. Further, it was found that 83% of all claims submitted were associated with off-label uses of the drugs. In addition, 20% of the 8.5 million claims for these drugs among Medicare recipients stemmed from billings for nursing home residents. 

All of these statistics pale somewhat in comparison to the finding that 22% of claims for the drug showed that they were not administered in accordance with CMS standards. This statistic becomes the beginning of a conversation as to how and why these drugs are dispensed in a nursing home setting, and whether the drugs are necessary at all in many cases. 

When one has an elderly relative who through necessity must be admitted to a nursing home, the thought process revolves around giving aid and comfort in the sunset of one’s life. The questions normally do not revolve around how often seniors’ brain chemistries are altered, well, just because. The questions that pop up in my mind are whether the reviewed drugs are being overused, whether anti-psychotic drugs are being used in lieu of sedation or restraint for patients with dementia, or (given that’s it’s me) whether we’re sending off old people to nursing homes that play old Iron Butterfly records over the loud speaker as the staff serves a vegan lunch while wearing tie-dye scrubs.

The very first OIG recommendation in the final report was for CMS to gain access to patient diagnostic information necessary to ensure that the claims are being reimbursed correctly. CMS did not agree with this recommendation, stating in response that diagnostic information isn’t generally included on prescriptions or pharmacy billing transactions. Without this information, CMS is unable to determine for what conditions the drugs are actually being used.

The information that could easily be made available would seem in this case to be of such importance as to warrant the inclusion of diagnostic data for drug claims, not just for this particular class of drugs, but for every other drug on the market. From cradle to grave, whether it be antibiotics or Grandma turning on, tuning in and dropping out, reliance on drugs to solve every medical problem has become the norm, rather than the exception. The OIG report this week was designed for financial reasons, but between the lines is a story about the quality of care senior citizens are receiving at end-of-life. Unfortunately, this story reads less like a peaceful, comfortable and medically appropriate ending and more like the screenplay for The Trip. 

This is your Grandma’s brain, and this is your Grandma’s brain on anti-psychotic drugs. Just say no.

Tags: ,
May 13th, 2011 | No Comments »

Of Royalty and Medicine

Posted by J. Paul Spencer, CPC, CPC-H in Industry Updates

It just figures. Today is my 45th birthday. Ideally, every person who has a birthday (depending on age) wants the day to be all about them. In the past, such things as the evacuation of Saigon in 1975 and the LA riots in 1992 have occurred to take the spotlight off of me.  So what happens on my birthday this year? A royal wedding in England. Of course, being that it happened at Greenwich Mean Time, we were all asleep, so that’s that. All things being equal, I have better hair than Prince William anyway.

While I’m on the subject of royalty, I have to admit to the reader that one of my favorite TV shows (currently on hiatus) is Royal Pains on the USA Network. The plot line of the show involves an ER physician in New York City who, half by happenstance and half by extraordinary demonstration of skill (it’s a TV show), ends up as a doctor-on-demand (commonly referred to as concierge medicine) for rich people in the Hamptons on Long Island. Thanks to the umbrella of suspension of disbelief that comes with television, the protagonist has treated people for such things as leprosy, lyme disease, hemophilia and parrot fever.   

Out in the real world, it turns out that concierge medicine is beginning to take hold across the country. A recent article in the Boston Globe indicates that due to long hours, enormous caseloads, insurance headaches and a desire to deliver more personalized care, physicians are slowly beginning to warm up to the concierge model.

Medicine on demand works like this. For a yearly retainer, usually in the $1,000-$2,000 range, you have access to a doctor at any time for any health issue. Concierge practices have varying policies with regard to insurance acceptance on top of the retainer. There also exist what are called “hybrid practices” in which doctors have an equal number of retainer-based patients and those with insurance coverage.

On the surface, provided you have money for both the initial outlay and insurance premiums, this sounds like a good deal. There are some catches though, the foremost of which being that there appear to be less than 800 physicians nationally with such a practice, according to an October 2010 government-commissioned study.

The article in the Globe tells the story of two high ranking internal medicine physicians who were affiliated with Newton-Wellesley Hospital in Newton, Massachusetts who joined a company based in Florida that assists physicians in running concierge practices. Soon, their practices that treat 3,000 patients apiece will shrink to 600, an 80% reduction in workload. This will feel like a great deal to the physicians and the 1,200 patients with care on demand, but for the patients of their former practice, it represents an unexpected barrier to primary care at a time when most medical school graduates are focusing on specialty medicine.

The basic idea behind the Patient Protection and Affordable Care Act was that every patient has access to insurance coverage. Medicare initiatives over the past year have focused almost solely on reducing costs. Access to quality health care is another matter altogether that has been largely ignored, save for provisions aimed to increase the number of medical school graduates that enter the world of primary care. The results of this particular initiative are more than likely a decade away from making a real difference in the current state of unbalance between primary and specialist care.

As it stands right now, concierge medicine does not represent a threat to the medical delivery system for those without the dollars to explore the option. Yet with the insurance industry in a downward spiral of offering fewer tangible benefits for ever-increasing premiums, the trend of concierge medicine is one that deserves close observation as we get closer to full implementation of PPACA.

Tags: , ,
April 29th, 2011 | 1 Comment »

« Older Entries
Newer Entries »