Washington — Democratic control of the White House and gains in both houses of Congress have raised expectations for comprehensive health system reform to their highest levels since the early 1990s, when the party last found itself in a similar position.
The results of the November elections prompted physician organizations to predict that 2009 will be an active year for reform. They’re calling on President-elect Barack Obama and Congress to expand health coverage to the 46 million uninsured and to take the lead on such issues as fostering primary care and medical homes.
“We think there’s that window of opportunity next year to really accomplish something,” said AMA Board of Trustees Chair Joseph M. Heyman, MD.
Ted Epperly, MD, the American Academy of Family Physicians’ president, said he has never before been so excited about a new president. “I believe that under his leadership we will finally start to make significant change toward health [system reform] in this country.”
It won’t be long before the new Congress and White House have the chance to test out their power arrangement with a major health access issue. The State Children’s Health Insurance Program will expire at the end of March, unless there is an extension or reauthorization. Attempts by Democrats this year to expand SCHIP coverage to millions of additional children were stopped by President Bush and his GOP allies.
President-elect Obama’s health reform plan would cost $65 billion a year.
With Obama at the helm, Democratic leaders in Congress already have set policy sights much higher. They want to cover as many of the nation’s uninsured as possible.
Senate Health, Education, Labor and Pensions Committee Chair Edward Kennedy (D, Mass.) plans to build off private meetings with representatives from myriad groups to seek consensus on comprehensive reform. Sen. Max Baucus (D, Mont.), chair of the powerful Senate Finance panel, detailed some of his plans for reform on Nov. 12. House Energy & Commerce Committee Chair John Dingell (D, Mich.) wrote a Nov. 10 letter to Obama asking to work with him on comprehensive reforms, starting with an SCHIP expansion.
Such individual efforts likely will merge into a single strategy, said Michael Myers, majority staff director for the Senate HELP Committee. “There’s a growing recognition that the best way, maybe even the only way, that this gets done is for Democrats to unite behind a single bill.”
Following Obama’s lead
Obama ran on a health platform of improving the employer-sponsored health insurance system, not dismantling it to try a new approach, such as a single-payer system. Democrats don’t plan to buck the next administration on that issue, Myers said.
Obama pledged to allow people who are happy with their job-based health insurance to keep it as is, but he promised that his plan would make it less expensive by creating a new national market for health insurance. He also pledged to cover more uninsured people in Medicaid and SCHIP.
At the present rate, the Medicare hospital trust fund will be exhausted by 2019.
Meetings among Democratic staffers have focused on how to translate the Obama plan into compatible legislation, Myers said. “Everyone in Congress, at least on the Democratic side and certainly Sen. Kennedy, is going to be taking their cues from the Obama White House on this effort.”
Obama supporters are mostly interested in getting help paying their health insurance, said Robert Blendon, ScD, a professor of health policy and political analysis at the Harvard School of Public Health. “We don’t find the evidence they were thinking of new ways to reorganize the health care system.”
Myers said that likely rules out legislation that would overhaul employer-sponsored health insurance, such as Sen. Ron Wyden’s (D, Ore.) bill.
Wyden’s bill, the Healthy Americans Act, would replace the employer tax exclusion with a standard tax deduction and an individual health insurance mandate. It would shift most Medicaid and SCHIP enrollees to new state-run insurance pools.
But Wyden said his measure shares many principles with Obama’s plan, such as strong support for preventive medicine and comparative effectiveness research. The AMA has not officially endorsed Wyden’s bill but has been supportive of his efforts to find a bipartisan approach to health system reform, Dr. Heyman said.
Obama’s call for fostering greater care coordination through medical homes echoes physician organizations such as the AAFP and American Academy of Pediatrics. He and the AMA also agree on the need to back income-based insurance subsidies and health information technology.
“I’m sure there are more areas where we can agree than areas where we might disagree,” Dr. Heyman said. Obama campaigned against ending the tax exclusion for employer-sponsored health insurance and replacing it with tax credits — part of the AMA’s uninsured proposal. The president-elect might be more supportive of expanding public health insurance programs than is the AMA, Dr. Heyman said. Still, both agree on the need for a mix of public and private solutions.
Finding federal funding
Obama gave no indication the economic recession was leading him to scale back his spending plans. Voters who backed him also have high expectations for health care change despite the financial challenges, Blendon said. “He can’t say, ‘I’m going to do nothing or something very small.’ “
The president-elect’s health system reform plan would cost at least $65 billion a year, according to estimates by his campaign staff. This figure assumes the reforms he proposes reduce health spending in other areas.
Experts said needed funding will be hard to find. The next Congress is inheriting a $10 trillion debt and has not made plans to address the more than 20% Medicare pay cut that physicians will receive in 2010. The Medicare hospital trust fund also is set to be exhausted by 2019. “This current Congress coming up needs right now to start dealing with that issue,” said Phil Roe, MD, an ob-gyn and Republican newly elected to Tennessee’s first congressional district.
But Dr. Epperly said the recession actually could further the cause of health system reform. People who have lost jobs and health coverage should be more apt to support new types of health legislation, he said.
Dr. Heyman said adopting comprehensive reforms is not primarily a matter of dollars. “If we have the political will to spend $700 billion in a week’s time to cure the economic crisis, which is a temporary problem, we ought to have the political will to spend much, much less money on compromising and finding a solution to this long-term problem.”
Continue Reading November 17th, 2008
Washington — The final Medicare physician fee schedule for 2009 shows just how large a bullet doctors dodged when they successfully lobbied Congress this year for a payment patch. It also spells out how some of them can move past that close call and secure a relatively healthy raise for next year’s work.
Legislation enacted in July reversed a 10.6% cut that took effect at the beginning of that month. Starting in January 2009, a 1.1% across-the-board increase will replace an additional roughly 5% cut that would have gone into effect if lawmakers had not acted, the Centers for Medicare & Medicaid Services said in the final pay rule issued Oct. 30. Because the rule applies payment changes related to the most recent five-year adjustment in Medicare relative values for certain services, some physician specialties might see updates slightly larger than or smaller than 1.1%.
“Medicare’s new rule confirms that physicians caring for seniors would have faced a harsh payment cut of 15.1% next year if Congress had not stepped in,” said American Medical Association President-elect J. James Rohack, MD.
The upcoming 1.1% boost will fall short of the CMS-projected 1.6% increase in the cost to physicians of providing care next year. Payment freezes and increases in recent years also have come in under the rise in costs. But the agency stressed that two bonus opportunities exist to more than quadruple the raise that doctors will get for the year.
Physicians who successfully participate in the Physician Quality Reporting Initiative will receive a 2% bonus on all of their Medicare payments for the year. Also, the program for the first time will award a separate 2% bonus to physicians who successfully prescribe medications electronically for their Medicare patients. Although the sums will not be paid out until sometime in 2010, after Medicare has processed all of next year’s claims, this means the maximum effective raise for 2009 will be 5.1%.
The rule gives more detail on how a doctor can secure an e-prescribing bonus. For example, he or she would need to have a qualified system that can adequately communicate with the patient’s pharmacy, identify appropriate drugs and lower-cost alternatives, provide formulary information, and generate adverse event alerts. A physician must report one of three special e-prescribing codes at least half of the times they are applicable. Claims containing the codes must represent at least 10% of all the services for which the physician bills Medicare for the year.
CMS envisions that the e-prescribing bonus will provide the “tipping point” for the health care industry as a whole to move to widespread adoption of the technology, the agency said in the final rule. The effects would go well beyond physician pay.
“E-prescribing can greatly reduce the number of medication errors that jeopardize the health and safety of Medicare patients and waste precious health care dollars treating conditions that never should have happened,” said CMS Acting Administrator Kerry Weems.
More enrollment headaches ahead?
Despite the prospect of more money on the table, physicians worry that more restrictive policies in other areas of the rule could increase the number of doctors who see their payments — or their ability to see Medicare patients — stop altogether.
“We are reviewing the 1,500-page rule now to determine how it addresses AMA concerns with proposals that would exacerbate already significant administrative hassles that take physicians away from patient care,” Dr. Rohack said Nov. 10.
Earlier this year, for example, the AMA and others strongly opposed a provision in the proposed 2009 fee schedule rule to clamp down on retroactive Medicare billing. Doctors cannot bill until they are officially enrolled in Medicare, but afterward they can bill for services provided as far back as 27 months from when their enrollment takes effect. CMS proposed limiting that retroactive billing to only 30 days before the date the enrollment application was successfully filed or the date a doctor started providing services at a new practice location, whichever comes later.
The organizations argued that the process of enrolling or re-enrolling in Medicare has turned into a complex process that often takes much longer than a month to complete. Backlogs on the part of Medicare contractors often make the process even longer, and the prospect that this could lead to a denial of retroactive payments means that a doctor waiting to enroll or re-enroll might be unable to see Medicare patients until the contractors resolve the problems, they said.
“Simply adding another ‘gotcha’ regulation to the mix will only make matters worse,” AMA Executive Vice President and CEO Michael D. Maves, MD, MBA, wrote in a comment letter on the proposed rule.
But CMS rejected the comments and adopted the new retroactive billing restrictions in the final rule. Agency officials insisted that they cannot know whether a newly enrolled physician met Medicare requirements prior to the date that the enrollment actually takes effect.
CMS in this case appears to be fixed on a solution in search of a problem, said Lisa Goldstein, government affairs representative with the Medical Group Management Assn. A practice taking on a new physician who needs to be enrolled in Medicare, for instance, would never risk the liability of having that doctor see Medicare patients if he or she were not in compliance with program rules, she said.
Goldstein said even more physicians could experience enrollment-related payment problems once the new restrictions take effect Jan. 1, 2009. Doctors are already citing widespread enrollment delays and payment stoppages related to this year’s Medicare contracting reforms and the move to the National Provider Identifier.
Some of the physician comments on the proposed rule did have a positive impact. CMS had planned to ban the use of computer-generated faxes to order Medicare drug prescriptions starting next year, but a strong response from the AMA and others caused the agency to push off that effective date until 2012.
Many doctors who have electronic medical records systems rely on computer-generated faxes for drug orders. A Medicare ban in 2009 likely would have driven a large number of them to revert to paper prescriptions rather than having the intended effect of moving them toward true e-prescribing, said Steven E. Waldren, MD, the director of the American Academy of Family Physicians’ Center for Health Information Technology.
Continue Reading November 17th, 2008
Tougher enforcement of federal rules for health information security likely is in store following a critical report by the Dept. of Health and Human Services Office of Inspector General.
In an Oct. 27 review, OIG chastised the Centers for Medicare & Medicaid Services for lax oversight of the Health Insurance Portability and Accountability Act’s security rule and for taking “limited actions” to urge compliance with the federal statute. The security rule requires covered entities — such as physicians, hospitals and health plans — that use electronic protected health information to employ systems to ensure the confidentiality of such data and safeguard them from unauthorized disclosures or security risks. Under HIPAA’s privacy rule, covered entities must make sure patient information is not shared with unauthorized parties.
CMS has maintained an effective process for receiving, tracking and resolving outside complaints filed with the agency since it began enforcement of the security rule in 2006, OIG noted. But that system does little to ensure that covered entities are using measures to stop breaches before they occur, the report said. In a national audit of several hospitals, the inspector general found “numerous, significant vulnerabilities in the systems and controls” intended to protect personally identifiable health information.
As of August 2007, CMS “had not implemented proactive compliance reviews and therefore had no effective way to determine whether covered entities were complying with HIPAA security rule provisions. Nor did CMS know how vulnerable [protected health information] was to attack by individuals intent on accessing and misusing” such data, OIG concluded.
Patients’ privacy depends on the security of health information, said Deborah C. Peel, MD, founder and chair of the consumer advocacy organization Patient Privacy Rights. “Privacy means you have control of the data, and you can’t have privacy as long as these databases are insecure. Even if you have a totally secure system, if you give out a thousand master keys, the security is meaningless.”
HHS received 379 security complaints over HIPAA in 2007.
Dr. Peel said such risks generally would not come to light in a largely complaint-driven process. “People can’t complain, because they don’t know what is going on in these complex systems,” she said, adding that most HIPAA security complaints start out as privacy breaches when patients realize their information was disclosed improperly.
According to the OIG report, the HHS Office for Civil Rights, which enforces the HIPAA privacy rule, received more than 16,000 complaints between 2003 and 2005, whereas CMS took in only 413 security-related complaints during the same period.
The inspector general recommended that CMS establish specific procedures for compliance reviews.
CMS disputes the findings
CMS disagreed with OIG’s conclusions, saying its complaint-driven enforcement process has furthered the goal of voluntary compliance.
“What the OIG defines as lax enforcement is very focused on the compliance review area, and we really consider our program to be much more than that,” said Anthony Trenkle, director of the CMS Office of E-Health Standards and Services.
CMS consented to implementing the compliance reviews recommended by OIG, he said. But the agency considers them a complementary tool in a comprehensive enforcement strategy that includes complaint investigation, education, and outreach to help physicians and entities identify and correct security issues.
“On one level you could say we’ve ratcheted [enforcement] up a bit,” Trenkle said. “But this has been a high priority and continues to be.” CMS completed 10 hospital compliance reviews and has begun developing criteria to initiate audits of a sample of covered entities, including physicians. The agency also is considering partnering with OIG on future compliance reviews, he added.
Given increased awareness of privacy and security risks, physicians can expect heightened enforcement activity, not only around HIPAA, but around other state and federal data protection laws as well, said Barbara Bennett, a HIPAA expert and partner at the law firm Hogan & Hartson LLP in Washington, D.C.
For example, HHS levied the first sanctions against a covered entity in July, when a hospital agreed to a $100,000 settlement for potential privacy violations. The agreement involved cooperation between CMS and the Office for Civil Rights.
HIPAA generally allows states to enact stricter privacy and security requirements than the federal government, Bennett noted. In addition, recent security breaches that led to medical identity theft have generated substantial media coverage and government scrutiny, she said. She pointed to the recent Federal Trade Commission’s “red flag” rules requiring physicians to implement a formal identity theft prevention program by May 1, 2009 — rules that could overlap with HIPAA regulations.
Bennett recommended physicians adopt a privacy and security compliance program in line with state and federal standards and continue to review its effectiveness. Adequate documentation is key, she noted. “Lack of documentation that the organization has made any effort to comply is the fastest road to liability.”
Continue Reading November 17th, 2008
Washington — Even as Medicare’s Physician Quality Reporting Initiative approaches the end of its 2008 run, many doctors are still trying to figure out what went wrong with the 2007 PQRI.
Confidential physician feedback reports from last year’s initiative, which for the first time offered Medicare bonuses for successfully reporting quality measures, became available to participating practices starting in August. Since then, many participants have been struggling to make sense of the information that they received — if they were able to access it at all.
Only about 20% of 408 physicians surveyed in September by the American Medical Association were able to download their 2007 feedback reports, which told each doctor whether he or she reported enough measures to qualify for a bonus. Nearly 60% of those who sought assistance from the Centers for Medicare & Medicaid Services in accessing the confidential reports said they received little to no help from the agency. For physicians who persisted and were able to get past the stringent security measures, fewer than half said they found the data instructive.
“The AMA is committed to working with policymakers to make this program a viable quality improvement tool for physicians,” said AMA Secretary Ardis D. Hoven, MD. “The survey shows a clear need for the program to be improved so that physicians can more easily participate and so that they and Medicare get greater value from the program.”
Physicians’ poor reviews of the initial six-month run of PQRI come at a critical time. For the 2009 reporting period that will start Jan. 1, the potential physician bonus will rise from 1.5% of all Medicare charges for the year to 2%. CMS officials hope to attract enough participants to the pay-for-reporting effort that it can develop into a robust pay-for-performance and quality improvement element for Medicare somewhere down the line.
But physicians who make the decision to participate in 2009 will be flying blind in one major way. Because they will not receive confidential reports on their 2008 reporting until the middle of next year, doctors will not officially know if they took the correct steps to secure a bonus until most of the upcoming yearlong reporting period has already passed. If some physicians don’t qualify for a 2008 bonus because they are not reporting correctly or their necessary information is not making it to CMS, they may find out the problem too late to salvage a bonus for 2009 as well.
Because of this high degree of uncertainty — and the fact that nearly half of participants in 2007 failed to qualify for an incentive payment — the AMA and other physician organizations are calling for major changes to PQRI. The Association is asking CMS to improve physician education and provide much quicker feedback to doctors so they can better determine if they are on track with their reporting before it’s too late. The AMA also wants physicians who are denied bonuses to be able to appeal the decisions, something that is not allowed under the current system.
Worries about 2009
Absent such changes, Patricia A. Cosgrove, MD, said she cannot know whether her practice will be successful in PQRI this year or the next. The Bozeman, Mont., ophthalmologist’s four-member practice reported quality measures in 2007, but she and two of her colleagues failed to receive bonuses, and the payment for the one doctor who qualified was significantly smaller than expected. The feedback reports that the practice downloaded with much difficulty and subsequent follow-ups with CMS have not been helpful in shedding any light on what went wrong.
“It is such an exercise in frustration to do everything we’re asked to do and then to not meet criteria and be talking into a void when it comes to trying to figure out how we can amend what we’re doing,” Dr. Cosgrove said. “We’re just trying to do the right thing.”
Less than half of the doctors who participated in Medicare’s PQRI in 2007 qualified for a bonus.
Because the office’s own records on its quality reporting don’t match what CMS noted on the reports, the physicians worry that Medicare is making errors somewhere and that their ability to obtain full-year bonuses for 2008 reporting is also in jeopardy. Still, the practice plans to keep reporting measures as best it can in 2009.
Although PQRI is voluntary, the incentives for physicians to participate keep ramping up. In addition to increasing the bonus size, CMS is making plans to share publicly the names of physicians who are successful quality reporters on its Physician Compare Web site, starting sometime in 2010. Dr. Cosgrove worries that any patient looking for her name on the site and not finding it might get the mistaken impression that her quality of care is somehow subpar.
“I don’t see it as being voluntary,” she said.
Some participating California doctors suspect they received no PQRI bonus for 2007 because the contractor handling the quality data said its system had no record of their practices. Physician delegates from the state proposed a resolution for the AMA’s Interim Meeting in November that would direct the Association to register a formal complaint with CMS and seek restitution for doctors who were erroneously denied bonuses.
Medicare acknowledges criticism
Some physicians already have given up on PQRI. About one-quarter of the respondents to the AMA survey said they had decided to drop out based on their 2007 experiences. Nevertheless, CMS is confident that many other doctors have worked through any problems that arose during the initiative’s debut and are in much better shape to achieve success this year and beyond, said an agency official who asked not to be identified so he could speak freely about the initiative.
CMS will continue to educate physicians about how to report quality measures correctly, the official said. The agency soon will release a list of common reporting problem areas encountered by physicians who failed to achieve bonuses in the 2007 PQRI. But producing faster personalized feedback to physicians would be more difficult because most of the reporting period would already be over before Medicare even had enough quality reporting data to compile in a report, he said.
The CMS official acknowledged doctors had a legitimate criticism that the 2007 feedback reports did not contain more detailed information. The agency already has plans to address that concern by including additional data in the 2008 feedback reports on how many reported measures were invalid and why those measures could not be counted.
CMS is focused on trying to get as many physicians as possible on board with PQRI in 2009 by expanding the quality measures that they can report and the ways that they can report them, the official said. “It’s important to focus on what we’ve learned from the 2007 program, but I also think it’s important not to dwell on it.”
Continue Reading November 10th, 2008
Washington — The uninsured aren’t to blame for overcrowding emergency departments seeking care for coughs and colds, a new study says.
Evidence suggests that uninsured patients visit EDs because of primary care access problems, according to a recent survey of scholarship on the issue. But the uninsured are generally not showing up in EDs for nonurgent care and they are not the primary reason EDs are becoming more crowded.
Manya F. Newton, MD, MPH, an emergency physician and University of Michigan professor, was reviewing academic articles for a project in early 2007 when she kept coming across stated assumptions about the uninsured that weren’t backed up with data. One such widely held belief was that visits by the uninsured were a major reason why EDs were becoming overcrowded.
“I began to question whether everyone did know this,” Dr. Newton said. “As an emergency physician I was certainly encountering these sentiments in my own [ED].”
She and four other authors examined 127 articles published between 1950 and 2008 that referenced uninsured people’s use of emergency departments. Their analysis compared assumptions in the articles with the best available evidence. The study appeared in the Oct. 22/29 Journal of the American Medical Association.
Medicaid enrollees are the most frequent ED users.
The authors concluded that researchers’ unsupported assumptions about uninsured people overusing EDs started to appear in academic articles in the early 1990s at the same time the administration started tighter enforcement of the Emergency Medical Treatment and Active Labor Act. That law, adopted in 1986, requires hospitals to treat people who need emergency care regardless of ability to pay.
Dr. Newton and her co-authors are not the first to debunk assumptions about ED use by the uninsured. In the last few years, she said, several academic researchers have published articles on the subject. But her study was the first comprehensive review of unsupported assumptions in peer-reviewed literature.
EDs are increasingly crowded because they’re seeing more aging patients with multiple illnesses, because the number of hospital beds has been declining for years due to financial pressures and facility closures, and because some patients want more immediate care and test results than they receive when visiting a physician’s office, said Bret Nicks, MD. He’s assistant medical director at Wake Forest University Baptist Medical Center’s emergency department in Winston-Salem, N.C.
The analysis, however, did find evidence to support a few common assumptions about ED use. These include statements that the uninsured visit EDs because of primary care access problems, that they’re less likely to be hospitalized than other patients with similar conditions and that the uninsured delay seeking care longer than other patients. “The uninsured tend not to show up for minor complaints,” Dr. Newton said.
The uninsured visit EDs for a variety of ailments but for one common reason: They’re worried, said David Ross, DO, an emergency physician at the Penrose-St. Francis Health Care System in Colorado Springs, Colo. “There’s something wrong with them … that worries them and they don’t have another place to go.”
Medicaid enrollees are the most frequent ED users. They visit about twice as often as uninsured people and Medicare beneficiaries, who in turn visit about twice as often as the privately insured, according to Centers for Disease Control and Prevention statistics.
Medicaid patients, especially those with young children, do sometimes visit the EDs because of coughs, colds and fevers, Dr. Nicks said. “A lot of times there are things that could simply wait to be seem by their primary care physician,” he said, but these patients might have trouble getting a timely appointment with a physician or any appointment at all.
Lawmakers should be careful about embracing false assumptions, Dr. Newton said. Laws to address problems that don’t exist or laws that ignore real problems could be the result. For example, steering ED patients with minor ailments to primary care physicians won’t work if the area has a doctor shortage, he said.
Continue Reading November 10th, 2008
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