06.30.08
Posted in Uncategorized at 9:00 am by ceo
Washington -- New laws in Colorado will enable physicians to review and contest health plan rating systems, patients to have standardized and possibly electronic health plan IDs, and insurance companies to develop new types of plans that the state may help consumers purchase.
Colorado Gov. Bill Ritter Jr. on June 3 signed into law a host of health care bills. Colorado Medical Society spokeswoman Edie Sonn said the measure regulating physician ratings could be a national trendsetter. It was influenced by a model developed by New York Attorney General Andrew Cuomo.
The measure requires health plans to make transparent their systems for profiling, rating or otherwise characterizing physicians, said Dave Downs, MD, the medical society's president. "The law basically says that if that data is publicly reported, they need to demonstrate its validity and accuracy of attribution." It also gives physicians a chance to appeal the ratings.
Jeremy A. Lazarus, MD, speaker of the AMA House of Delegates, said, "The work of the Colorado Medical Society will help create a much fairer environment for physicians to practice medicine in, and shows that with the concerted action of physicians working together, we can achieve our goals."
The law arose from discussions between insurers and physicians in an advisory council assembled when UnitedHealth Group and PacifiCare Health Services Inc. merged in 2006. Michael Huotari, executive director of the Colorado Assn. of Health Plans, said the talks that led to the law were relatively harmonious.
"We realized that we had some fundamental agreements, surprisingly, about how this should be done in terms of principles and concepts," he said. These include using statistically valid numbers and giving physicians prior notice of the ratings and a chance to correct and appeal them.
Colorado has roughly 800,000 uninsured.
Ritter also signed several other bills on June 3. They expand access to Colorado's State Children's Health Insurance Program and direct the Division of Insurance to create a shopping guide for private health insurance on its Web site.
Also, the fiscal 2009 budget will increase Medicaid reimbursement for physician evaluation and management codes from about 68% of Medicare to 90% of Medicare at a cost of $29 million. Hospitals will see a 1.5% Medicaid reimbursement boost estimated to cost $4.4 million.
Another new law will mean that health plans' ID cards soon will carry the same basic information and in a few years could be a tool to improve health care efficiency and quality, Huotari said.
The law first requires health plans to adopt standardized ID cards that indicate the subscriber's co-payment and deductible amounts, among other information, by July 1, 2010. The law also creates a stakeholder work group to decide what additional information -- such as coverage limits -- health plan IDs should contain and what form the IDs should take. A credit card-style ID that can be swiped is one possibility.
The work group, which will include physicians, is expected to finish its recommendations no later than mid-2009, according to the law's provisions, with a goal of implementation two years later.
The panel is expected to seek advice from the Workgroup for Electronic Data Interchange, of which the AMA is a member. Health plans have anticipated this advance in technology and support the law, Huotari said. The Colorado Medical Society also supports the law.
Should electronic IDs become reality, Dr. Downs doesn't expect the measure to lead to major equipment or software purchases for physician practices. A typical credit-card style reader costs about $100, Sonn said.
Electronic IDs present the opportunity to reduce medical errors if they allow physicians to access a patient's medical history quickly, said Rep. Anne McGihon, chair of the Colorado House Health and Human Services Committee. "You're not going to have to run the same test again, but you're going to immediately know what that person had," she said.
Setting up a mandate?
Some of the legislation followed recommendations of the Blue Ribbon Commission for Healthcare Reform, a panel created in 2006 by the General Assembly. The commission's ideas focused on expanding health care access to the state's roughly 800,000 uninsured, while maintaining choice, reducing health care costs and improving quality.
Richard Haugh, spokesman for the Colorado Hospital Assn., said the panel set the tone for the 2008 legislative session.
"[The commission] probably did a lot to foster an atmosphere of collaboration. I expect to see that going forward, too," he said.
One of the new laws requires insurance companies to work with two state agencies to design "Centennial Care Choices," a program geared toward the uninsured in which private health plans could provide basic coverage. This follows a Blue Ribbon Commission recommendation to establish a minimum-benefit health plan with a target premium of $200 a month for an individual. The proposal is part of a commission recommendation to establish an individual insurance mandate in Colorado.
The Centennial Choices law requires the new plans to include primary and preventive coverage, offer incentives for healthy behaviors and use pay-for-performance programs where appropriate. But it was written with controlling costs in mind.
"It kind of turns the usual process on its head," Huotari said. Plans will determine how much it costs to offer certain benefits and work with state agencies to design the plans. The hope is that it will be flexible enough to allow insurance companies to innovate, Huotari said.
The Colorado Medical Society and the hospital association both support the Centennial Care Choices law. "In general, it's a great stepping stone toward health care reform," Haugh said.
The medical society also supports requiring people to have health insurance but doesn't have an official position on how a mandate should be structured. "We're very agnostic on the way you get there," Dr. Downs said.
McGihon said the key to adopting an individual mandate is making sure it's part of a comprehensive plan to advance health care access.
Any significant expansion of access to health care or insurance will require more public funds, which under Colorado's strict constitution means asking voters for approval, McGihon said.
Still, she was optimistic about the state's chances of covering more of its residents. "You should keep your eye on Colorado. We are just starting down the road to comprehensive health care reform."
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Posted in Uncategorized at 9:00 am by ceo
Washington -- Selected primary care physicians in a dozen communities will receive potentially tens of thousands in additional Medicare dollars for using certified electronic health records systems under a demonstration project starting next year.
Over the five years of the project, each doctor chosen for the demo could receive up to $58,000, with a limit of $290,000 per practice. The initiative will operate in Alabama; Delaware; Georgia; Louisiana; Maine; the Maryland/Washington, D.C., area; Oklahoma; and Virginia. The other communities are multicounty areas centered on South Dakota; Jacksonville, Fla.; Madison, Wis.; and Pittsburgh.
The Centers for Medicare & Medicaid Services will work with partners in Louisiana, Maryland, Pittsburgh and South Dakota starting this fall to recruit 200 small- to mid-sized primary care physician practices to participate in each community when the demonstration begins in June 2009. Projects in the remaining eight communities will launch one year after the initial four.
Physicians do not necessarily need to be first-time EHR adopters to qualify for the bonuses. Federal officials expect that many of the participants already will have a certified system.
Participation will not necessarily ensure extra Medicare payments. CMS randomly will choose only half of the 200 practices recruited in each community to get EHR incentive payments. The other half will serve as a control group and will get no bonuses, even if they use certified systems.
Practices that are put into the control group will know from the outset and will need only to fill out an annual survey of their EHR status. They will receive a small fee for filling out the paperwork. CMS wants to see how that group progresses in IT adoption without receiving any incentives. No one in the control group will be required to use an EHR. Incentive payments will not be available to non-primary care doctors or to practices with more than 20 physicians.
The size of the payments will be based in part on how sophisticated a practice's system is and whether the practice reports certain clinical quality measures defined by CMS for preventive care and the treatment of diabetes, congestive heart failure and coronary artery disease. In years three through five of the demonstration, Medicare will pay bonuses in large part based on how practices perform on these quality measures.
The administration is focusing on smaller physician practices because they have not embraced EHRs as quickly as federal officials would like. President Bush has proposed that most Americans have an electronic record by 2014.
"The gap between those who practice in small- to medium-sized offices and those who practice in larger offices or organizations is continuing to widen," said Karen M. Bell, MD, director of the office of health IT adoption for the Dept. of Health & Human Services. "This underscores our need to concentrate on those clinicians who, as it turns out, constitute the majority of practitioners in the U.S."
The American Medical Association said the federal incentives would be important to primary care practices in the 12 communities -- if the payment structure works.
"This a step toward wider use of new technologies that can help improve health care quality, and we look forward to the program findings, as we would like to see effective EHR programs expanded to cover other areas of physician practice," said AMA Board of Trustees Chair Joseph M. Heyman, MD.
Slow going
Efforts to encourage physicians to adopt electronic health records have not yet had a widespread impact. A survey of nearly 2,800 doctors by researchers at Massachusetts General Hospital and published June 18 in the New England Journal of Medicine found that only 4% of physicians reported having an extensive, fully functional EHR system, and only 13% said they had a basic system. Many of the physicians who did not use electronic systems cited cost concerns as a major barrier to adoption.
The researchers said Medicare health IT bonuses could play an important role in creating a new landscape for paperless medical records.
"Our data suggest that such incentives could be important facilitators of adoption," the authors write. "However, the cost of achieving widespread adoption of electronic health records in the United States could be high, probably in the tens or hundreds of billions of dollars, and whether any future federal administration will find the necessary resources is uncertain."
The promise of up to $58,000 in additional Medicare payments could attract some small physician practices that are on the fence about EHRs because of the cost, said Timothy G. Ferris, MD, MPH, medical director of the Massachusetts General Physicians Organization and one of the study's authors. But direct and indirect implementation costs of taking on a new system can be significant over time, and the additional Medicare money likely will only be enough for most practices to break even, he said.
"Every little bit helps, but I don't think the effect will be very dramatic in terms of new adopters," he said.
One physician who understands well the indirect costs that can come with going paperless is Richard J. Baron, MD, a Philadelphia internist. The five-physician practice he founded decided in 2004 to adopt a fully featured EHR system, and he described the process as the most difficult thing that his small business has done. Although the system eventually transformed patient care, unexpected startup and maintenance costs combined with decreased productivity during the transition took its toll at first.
"The experience in our office was that it cost us over $40,000 per doctor and that we saw a 2.5% absolute decrease in revenue in the year in which we implemented," he said. "In a business where your costs are fixed costs and your income as a physician is what's left at the end of the year, you can double a revenue decrease in terms of its impact on salary."
Dr. Ferris said the more promising element of the demonstration would be in testing a new way for Medicare to pay for patient care beyond just funding medical services. Whether the model succeeds should depend on what effect it might have in improving clinical outcomes, efficiency of care and patient satisfaction, he said.
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06.18.08
Posted in Uncategorized at 1:38 pm by ceo
This article from the New York Times talks about how unhappy doctors are. They are overworked because they spend too much time dealing with insurance companies and patients who think they know something. Here’s a story that comes from a friend of mine (not from the article):
A patient comes in with 2 days of congestion and basically a viral common cold. I examine them and give advice on how to treat the symptoms. Patient then demands a “z-pack”. I then spend the next 10 minutes explaining and basically arguing with the patient that they don’t need a z-pack and that giving it is not indicated for a virus. Now I’ve spent 15 minutes for what should have been a quick 5 minute appt. Waiting room is backed up and everyone’s pissed including the patient I just saw.
2 days later, I get a letter from one of the local urgent care centers saying they treated this patient for a “sinus infection” with a z-pack. Now, the patient’s insurance has not only paid for my visit, but they’ve paid for the urgent care visit which is usually at a 25% higher rate because it’s “urgent”. Oh, and the patient got an antibiotic they don’t need and further helps spread antibiotic resistance in the community. It’s a friggin joke sometimes.
This story helps show some of the problems. Insurance companies are paying for unnecessary stuff (but not paying for stuff they should cover).The other problem is the time doctors spend dealing with insurance companies who, of course, have clerks arguing with doctors about medical decisions. There’s a good example of that in the article.
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06.16.08
Posted in Uncategorized at 1:58 am by ceo
Washington -- At the end of the first week of June, lawmakers introduced legislation that would cancel the scheduled July 1 Medicare payment cut to physicians. But very little time is left to iron out funding disagreements between Democrats and Republicans.
Senate Finance Committee Chair Max Baucus (D, Mont.) on June 6 introduced the Medicare Improvements for Patients and Providers Act of 2008. The bill would replace the upcoming 10.6% reduction with a rate freeze for the remainder of the year. In 2009, physicians would receive a 1.1% raise instead of an estimated 5% cut.
Sen. Charles Grassley (R, Iowa), the Finance Committee's top Republican, two days earlier unveiled the outline of a competing GOP bill that would include the same payment changes. But Baucus and Grassley have different ideas about how to fund the six-month rate freeze and the year-long raise.
The Baucus bill would focus primarily on reducing Medicare payments to private insurance companies through Medicare Advantage, in part by removing nearly $2 billion from a special fund designed to keep insurers in the program. At press time, Grassley had not specified how Congress would pay for his bill but said that it would not focus so heavily on Medicare Advantage.
The disagreement is significant and caused Senate Democrats to break off negotiations with their Republican colleagues several weeks before each side unveiled its own measure. White House officials said that President Bush would veto any legislation that targeted Medicare private plan payments, and Senate Democrats cannot obtain the 60 votes necessary to end debate and move to a final vote unless several more lawmakers cross the aisle on this issue.
Finance Committee members Olympia Snowe (R, Maine) and Gordon Smith (R, Ore.) are the only Republicans so far who have thrown their support behind Baucus.
With few remaining legislative days before the onset of the July 1 cut, the policy gulf between the two sides prompted some lawmakers to start to consider backup plans. Congress could pass a six-month payment patch or another short-term measure to buy more time to work out the longer-term funding dispute, congressional aides said. Alternatively, Congress could allow the 10.6% cut to take place temporarily and continue working toward an 18-month bill that would pay physicians retroactively for their lost payments soon after the measure obtained final approval.
Whatever path Congress takes, some physicians might see at least a few smaller Medicare checks before they are paid what lawmakers decide they deserve. Officials with the Centers for Medicare & Medicaid Services in May issued a warning that President Bush would need to sign any congressional compromise by mid-June if the agency were to have enough time to send amended payment instructions to Medicare carriers.
Physician support for bills
Despite the funding dispute, physician organizations expressed optimism that Congress would come to an agreement in time to stave off the upcoming reduction.
"The AMA commends Chairman Baucus for his leadership in working to enact legislation that will stop looming Medicare physician payment cuts that begin in less than 30 days," said Edward L. Langston, MD, then chair of the AMA Board of Trustees. "We look forward to reviewing the details of Senator Grassley's legislation to avert a Medicare access-to-care crisis as well, and we remain committed to final action before July 1 to ensure seniors' continued access to physician care."
The physician payment piece is not the only provision of interest to doctors in the roughly $20 billion Baucus bill and the outlined Grassley bill. Physicians starting next year would receive financial incentives of up to 2% of their Medicare payments for using electronic prescribing. The bonus would phase down to 0.5% in 2013. Starting in 2011, physicians would be required to use e-prescribing and would be penalized by at least 1% and eventually as much as 2% of their Medicare pay if they did not.
The AMA is pleased that the Baucus and Grassley measures both include bonus payments for e-prescribing, but Dr. Langston reiterated that the government must finalize standards for use of the technology, as well as lift a prohibition on electronic prescriptions for controlled substances, before physicians nationwide can go paperless with drug orders.
The American College of Physicians endorsed the Baucus legislation and wrote letters to lawmakers urging them to approve the bill. In addition to the 18-month physician payment piece, the measure includes provisions that particularly would benefit primary care physicians, including higher payment based on relative values for primary care services, increased funding for a Medicare medical home demonstration project and additional bonuses for primary care doctors working in underserved areas.
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Posted in Uncategorized at 1:58 am by ceo
Washington -- Ninety-five percent of Massachusetts tax filers for 2007 said they met a state mandate to have health insurance -- a compliance rate that health system reform stakeholders touted as a sign the new program is working.
"It's been wildly successful," said Mario Motta, MD, president-elect of the Massachusetts Medical Society, especially enrollment in the state-subsidized private plans for people earning 300% or less of the federal poverty level.
Brian Rosman, research director at Health Care For All, a Massachusetts patient advocacy organization, was impressed that so many residents met the new requirement. "I was frankly expecting a much higher noncompliance rate, like 15% or 20%."
The findings are based on a Massachusetts Dept. of Revenue analysis of 86% of the expected 2007 tax filers, or about 3.3 million people. Insurance status is self-reported on tax returns and will be verified by the Dept. of Revenue.
Massachusetts residents are required to have health insurance, prove they cannot afford it or pay a tax penalty, which will rise from $219 in 2007 to a maximum of $912 for the 2008 tax year.
Of the 5% of residents who said on their 2007 tax returns that they don't have health insurance, about half, or 2.5% of tax filers, were deemed by the state to be able to afford coverage. They were subject to the $219 penalty. Another 2% of tax filers were deemed unable to afford health insurance and were exempt from the mandate.
43% of Massachusetts hospitals have too few family physicians; 54% don't have enough internists.
The individual mandate's impact is reflected in the state's uninsured rolls. The percentage of people lacking coverage dropped from 13% in fall 2006 to 7.1% by fall 2007, according to an analysis of two phone surveys of about 3,000 adults published online in Health Affairs June 3. The period was the first year the state implemented its health system reform, the Commonwealth Connector program.
To help people afford coverage, Massachusetts offers subsidized insurance to those earning 300% of poverty level or less through private plans participating in the part of the reform program called Commonwealth Care. People earning 150% of poverty or less are eligible for virtually free insurance. Residents with incomes above 300% of poverty have access to unsubsidized insurance through private plans operating in the Commonwealth Choice portion of the reform program.
By now there are likely even fewer uninsured residents than in fall 2007, and there will be fewer still in the future, said Jon Kingsdale, PhD, executive director of the Connector Authority, the organization implementing the health system reforms.
"I don't know what it's going to get down to, whether it's going to be 2% or 3% overall. I'm really not sure," he said. "I do know it's going in the right direction, which is a contrast with the direction the rest of the country is going in."
Some experts had feared businesses would pay an annual $295 fee per employee in lieu of offering coverage, but the survey revealed that the percentage of adults between 18 and 64 with employer-sponsored coverage grew. For example, in fall 2006, 37.7% of adults in families earning less than 300% of poverty level said they had coverage from their workplace, but that increased to 42.3% by fall 2007. For adults at all income levels, employer-sponsored coverage increased from 66.6% in fall 2006 to 69.3% in fall 2007.
Still, concerns about the ever-increasing cost of health insurance and health care in general are worrisome, Kingsdale said. The reform program is millions over budget because of higher-than-expected numbers of uninsured people and because many more people than anticipated enrolled in the subsidized Commonwealth Care plans.
"If we don't control the cost of medical care and health insurance and moderate the increase yearly, I don't think near-universal coverage is sustainable," he said.
Physician shortage a concern
The phone survey also showed that while Massachusetts residents had better access to health insurance, finding a physician was not getting easier. "The availability of primary care is the single biggest problem [for the reforms]," Dr. Motta said.
The analysis found that 6.9% of adults in families earning less than 300% of poverty reported in fall 2007 that they did not get needed care in the past year because of trouble finding an available doctor or other health professional. That is up from 4.1% in fall 2006. For all adults, that percentage increased from 3.5% in fall 2006 to 4.8% in fall 2007.
Dr. Motta said Massachusetts' physician shortage isn't obvious when counting the number of licensed doctors. Some doctors work for academic hospitals and see only a few patients a week, while others conduct research for pharmaceutical companies and other entities.
"On paper, it makes us look like we have an overabundance of physicians," he said. In contrast, the MMS 2007 Physician Workforce Survey reported a critical shortage of internists and a severe shortage of family physicians. For example, 43% of community hospitals in 2007 said they faced family physician shortages, and 54% reported a shortage of internists.
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