E-DMN - March 1, 2010

March 1, 2010

Editor's Column: Strategy In A Two-Front War
Beaumont CEO To Retire May 31; Successor Named
Governors On Health Reform: 'We Want In'
WSUSOM Has Banner Year For Fertility Help
Oakwood Health Professionals Participate In '100 Days To Health' Activities
Providence Hospital Study Finds MRI Safe For Patients With Heart Devices
AMA Health IT Webinar Series Available For Viewing
Doctor Shortage Fuels Nurses' Push For Expanded Role

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Editor's Column: Strategy In A Two-Front War

By JOSEPH WEISS, MD
We face a two-front financial war.

The first is at the federal level. The US Senate has ruled there will be no change in the Sustainable Growth Rate (SGR), the formula Medicare uses to determine physician compensation. Coming March 1, and for the next six months at least, we will be reimbursed under a last-minute congressional resolution maintaining payment for the future as set in the past. That means the January payment sticks with a 21 percent decrease looming in six months. Remember, six months from March 1 is October 1, just 32 days before the November national elections. In October 2010, Congressmen will likely be even less interested than they are now to increase our reimbursements, let alone make a change that reforms the way we are paid.

We should not blame our leadership for this failure in financial reform. The AMA, specialty societies and individual physicians undertook advocacy to its fullest but could not overcome the obstacles that made reform impossible. As a result of the faltering reform, we can expect little change in reimbursement for the foreseeable future, i.e., for years.

The alternative strategy is to increase reimbursements working through our specialty societies as cardiology did when it blocked a proposed federal 10 percent decrease in reimbursements for their membership for 2010. Unfortunately, this policy weakens the bargaining power of the AMA as it represents the medical community.

The second warfront is the reemergence in Michigan of a possible physician tax. Last year this proposal barely passed the state House only to see the state Senate crush the measure by a 33-4 nay vote. The same should occur this year if the proposal put forward retains the sloppy and murky content of last year’s bill (see Editor’s Column, January/February 2010 Detroit Medical News magazine).

However, Michigan physicians must exercise vigilance and respond with an active protest to assure ourselves that complacency will not exact cruel punishment upon us.

Michigan physicians are not paranoid when they consider themselves under siege. Recall that in World War II, the citizens of Leningrad fought off encirclement for four years, we must be prepared to do the same.

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Beaumont Hospitals CEO To Retire May 31; Successor Named

Beaumont Hospitals President and Chief Executive Officer Kenneth J. Matzick has announced his retirement effective May 31 after 41 years, the last five as chief executive.

Beaumont's Board of Directors has appointed Gene Michalski, executive vice president and chief operating officer, as Beaumont's new president and CEO effective June 1.

Matzick joined Beaumont as an assistant director in 1969, later becoming the first director of Beaumont Hospital, Troy when it opened in 1977. He then moved to Beaumont Hospital, Royal Oak, first as director, and then vice president and hospital director. He served as executive vice president and chief operating officer for the corporation from 1997 to 2005, when he was named as Beaumont's president and CEO.

Under Matzick's leadership, Beaumont became a three-hospital system with the acquisition of the former Bon Secours Health System in Grosse Pointe in 2007. It also created an ambulatory care division that expanded its geographic reach with a network of community-based medical centers in Oakland, Macomb and Wayne counties.

During his tenure, Beaumont also developed a medical school partnership with Oakland University. The new Oakland University William Beaumont School of Medicine [2] received preliminary accreditation in early February and is on track to begin instructing its first class of students in fall 2011.

The last two years have been among the most challenging in Beaumont's history. Economic conditions in the region resulted in diminishing patient volumes and revenue causing Beaumont's first financial loss at year-end 2008. A financial turnaround plan initiated by Matzick in November 2008 has since turned the organization back to profitability.

Matzick's successor, Gene Michalski, has been part of the Beaumont organization since 1971, serving as associate hospital director of Beaumont, Royal Oak, senior vice president and hospital director of Beaumont, Troy and as executive vice president and chief operating officer since 2006. He was executive vice president and chief operating officer at Saint Francis Hospital in Evanston, Ill., from 1992-1996.

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Governors On Health Reform: 'We Want In'

"Some governors, frustrated by halted federal efforts to overhaul the US health-care system" and by lingering budget shortfalls deepened by rising health costs, "are introducing their own changes at the state level," The Wall Street Journal reports. While some states, such as Massachusetts, have already taken on health care, others, such as Colorado, Pennsylvania and Republican-led Utah, are now tackling the issues, including cost. "Some governors suggested they may be better equipped to work with one another on health care than congressional leaders who have been at an impasse over federal legislation" (Thiruvengadam, 2/22).

Governors continue to worry that some federal "reform proposals could deepen the budget woes that many states face," Reuters reports, adding: "Medicaid, the healthcare program for the poor jointly administered by the states and government, is already one of the largest single budget items for many states. Governors fear more people will be forced to rely on the program if they are compelled to get health insurance." The governors, who were meeting in Washington this weekend, plan to present that concern to President Obama Monday. But, "[o]n the other hand, they also fear that doing nothing will also worsen their financial situations" (Lambert, 2/21).

Governors also used this weekend's meeting to tout "progress in their own jurisdictions to reduce healthcare costs and improve quality," according to Modern Healthcare. Gov. Deval Patrick challenged other states to catch up with Massachusetts' rate of insurance coverage, 98 percent. And, "Pennsylvania Gov. Edward Rendell said his state now requires that emergency department facilities provide a non-emergent care facility that's accessible around the clock," which saves money (Lubell, 2/21).

NPR interviewed Gov. Gary Herbert, R-Utah and Gov. Joe Manchin, D - W.Va., who said: "We've got to change health care. Health care has double digit inflation for every state. I don't believe that we've bottomed out as states. We know we have tougher times ahead of us." Herbert said: "I think some of the concerns that we have in Utah and other states is the overreach of the federal government. It's not like we're looking for anything. In fact, sometimes we're looking just, you know, kind of stay away" (Lyden, 2/21).

This is part of Kaiser Health News' Daily Report - a summary of health policy coverage from more than 300 news organizations. The full summary of the day's news can be found here and you can sign up for e-mail subscriptions to the Daily Report here. In addition, our staff of reporters and correspondents file original stories each day, which you can find on our home page.

This information was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. You can view the entire Kaiser Daily Health Policy Report, search the archives and sign up for email delivery. © Henry J. Kaiser Family Foundation. All rights reserved.

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WSUSOM Has Banner Year For Fertility Help

The directors of the Wayne State University School of Medicine’s Division of Reproductive Endocrinology and Infertility have announced a “banner” year for helping couples achieve pregnancy in their Wayne State University Physician Group practice.

The division had its most successful year ever in 2009, said Elizabeth Puscheck, MD, MS, professor of Obstetrics and Gynecology, In Vitro Fertilization director and Gynecologic Ultrasound director, and Manvinder Singh, MD, associate professor of Obstetrics and Gynecology and the Division of Reproductive Endocrinology and Infertility.

The division reports its rates of in vitro fertilization to the Society of Assisted Reproductive Technology, which tracks figures for infertility clinics across the nation.

The most recent SART information available shows the national success rate of births from non-donor fresh embryo transfers for women below the age of 35 is 45.8 percent (38,372 attempts nationally). National pregnancy rates using thawed embryos for the same age range is 34 percent.

While SART policy states that a comparison of individual clinic success rates may not be meaningful because patient medical characteristics, treatment approaches and entrance criteria may vary from clinic to clinic, the WSU division showed higher levels of success percentage-wise than national averages.

The Wayne State University clinic’s success rate for non-donor fresh embryo transfers in 2009 reached 78 percent. In the implantation of thawed embryos, the clinic achieved pregnancy rates of 54 percent in women below the age of 35.

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Oakwood Health Professionals Participate In '100 Days To Health' Activities

Oakwood Healthcare System is the principal healthcare sponsor of Canton’s ambitious annual 100 Days to Health, a program of recreational and fitness activities, conferences, classes, demonstrations and special events promoting “A New You for the New Year” for Canton area residents.

100 Days to Health, which actually will last for ninety-nine days, from January 16 to April 26, 2010, attracts hundreds of interested men and women of all ages and conditions. It targets local families who want to get and stay healthy together, but it offers something for everyone and every schedule.

The program was created eight years ago as a summer series, but later was moved to its present dates in response to residents looking for winter activities and help keeping their New Year’s fitness resolutions. More than 500 families were expected to register this year for its mostly free lineup.

An important and popular part of 100 Days to Health are the Oakwood physicians, clinicians and other professionals engaged throughout the event to present on 10 different health and healthcare topics. This is information participants have asked for and that highlights Oakwood’s related areas of specialty.

The 2010 roster of Oakwood speakers and topics includes:
Diane Droba, RN, AE-C, on Chronic Health Issues in School-Age Children – Emphasis Asthma
Angelo J. Sorce, MD, on Bone Disease and Disorders - Orthopedic Solutions
George Nahhas, MD, FACC, on Improve your Heart Health in 2010
Kranthi K. Myneni, Physical Therapist, on Stress Relief through Movement and Relaxation
Majd A. Aburabia, MD, on Breast Health – Latest Test and Screening Recommendations
Asheesh Tewari, MD, on Eye Diseases and Disorders – 21st-Century Solutions
Gerald Petrosky, RPh, on Over-The-Counter Remedies, Vitamins and Supplements
Jeffrey Kline, Director, Sports Medicine, on Youth Sports Injury Prevention
David Sengstock, MD, MS, on Caring for or Living with an Older Adult with Dementia
Christina Lucas, DO, on Get the Most from Your Doctor Visit or Regular Check-Up

These presenters were engaged through the Oakwood Speakers Bureau, which provides lecturers and information centers to scores of nonprofit organizations, agencies and groups in Oakwood’s central, western and downriver Wayne County service area each year.

Registration in 100 Days to Health is just $15 for Canton residents ages 16 and older, $5 for Canton kids ages 4 to 15, and free for children age 3 and under. The cost for non-Canton residents is $25 for adults and $5 for kids.

For more information, call the 100 Days hot line at (734) 394-5496 or go to “Events” on http://leisure.canton-mi.org/

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Providence Hospital Study Finds MRI Safe For Patients With Heart Devices

There is more evidence that patients with implantable heart devices can safely undergo an MRI. In a study at Providence Hospital, published in the online edition of the Journal of Interventional Cardiac Electrophysiology, researchers found that the scans did not harm the patients or damage their devices.

Historically, MRI has been considered dangerous in most patients with defibrillators, pacemakers and loop recorders due to potential adverse effects on the device from the strong magnetic and radio frequency forces generated during the scan.

For this study a total of 92 MRI scans were performed in 38 patients. Researchers found that the scans did not cause any device circuitry damage, programming alterations, inappropriate shocks, failures to pace, or changes in sensing, pacing, or defibrillator thresholds.

“This adds to a growing body of evidence that MRI scans can be done safely on people living with implantable heart devices, says Christian Machado, MD, electrophysiologist at the Providence Heart Institute and the principal investigator. “It’s clear that if treated using the proper protocol, these patients no longer need to be excluded from receiving this potentially lifesaving diagnostic test.”

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AMA Health IT Webinar Series Available For Viewing

A four-part series of online education programs offering tips on how to successfully implement health information technology (IT) and improve your practice’s efficiency and quality of care is available to be downloaded from the AMA Web site.

Offered by the AMA and TransforMED, a subsidiary of the American Academy of Family Physicians, the series covers such topics as meaningful use, preparing for health IT, system selection and implementation strategies, and how patient engagement in using technology positively affects the practice. Programs originally were broadcast live during a four-week period from Jan. 14–Feb. 4.

Visit http://www.ama-assn.org/go/hit and click on “Health IT webinars” to view each program in the series as well as slides from each.

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Doctor Shortage Fuels Nurses' Push For Expanded Role

Nurse practitioners - like Irene Cavall in North Carolina - are gaining support in their drive to play a larger primary care role. But the powerful AMA is waving a yellow caution flag before state regulators and legislators. (Ron Vick/KHN)

There are no doctors in rural Tyrrell County, N.C. There is only Irene Cavall, a licensed nurse practitioner and the sole source of primary care for 4,000 residents spread out over 600 square miles.

It’s been that way since the county’s lone doctor moved away two-and-a-half years ago. Cavall sees as many as 40 patients a day at the Columbia Medical Clinic. It’s about 40 miles west of the Outer Banks; an ambulance ride to the nearest hospital takes 25 minutes.

There are limitations to her work – by state law, she works under the supervision of a doctor, albeit one many miles away, and calls him and specialists as needed. But for 15 years, Cavall has been helping patients with a range of routine problems, from colds to management of diabetes, that don't always require a doctor. As she says, doctors "don't need to give someone a Tylenol."

Nursing leaders say large numbers of practitioners like Cavall will be needed to fill gaps in primary care left by an increasing shortage of doctors, a problem that would intensify if Congress extends health insurance to millions more Americans. Advocates say nurse practitioners have the extra education and training needed to perform a variety of services, including physical exams, diagnosis and treatment of common ailments and prescribing drugs.

But the American Medical Association and doctors' groups at the state level have been urging state legislators and licensing authorities to move cautiously, arguing that patient care could be compromised. This battle has been waged for years, even as nurse practitioners grew rapidly in number — there are 125,000 or more — and expanded their responsibilities. What's different now is the increasing conflict as pressure grows to use nurse practitioners and other so-called physician extenders, including physician assistants, certified nurse midwives and pharmacists. The American Association of Medical Colleges estimates that there will be a shortfall of as many as 46,000 primary care doctors by 2025.

Doctors Push Back

The American Medical Association sparked harsh criticism from nursing groups when it released a report in October bluntly questioning whether nurse practitioners "are adequately trained to provide appropriate care." To back up its claims, the report cites recent studies that question the prescription methods of some nurse practitioners, as well as a survey that reported only 10 percent of nurse practitioners questioned felt well prepared to practice primary care.

The nation's largest doctors' group concluded: "The time is ripe for legislators, health care policy analysts and nurses to thoroughly assess the quality of NP training in relation to the scope-of-practice expansions sought at the state level."

Responding to the AMA in December, the American Nurses Association and more than two dozen other nurses' organizations termed the report "misleading," saying it “contains numerous factual misrepresentations.” Their letter rebuked the AMA for its “attempt to change the perceptions of NP practice as anything other than fully qualified professionals working within a legally established scope of practice.”

(Ron Vick/KHN)

The president of the American Society of Anesthesiologists says the key issue is supervision "We understand that in most fields of medicine, non-physician providers play an important role and they certainly have in anesthesia for more than a century," says Dr. Alex Hannenberg, who practices in the Boston area. "The safest and high quality care requires that a physician be providing oversight of the nurse practitioner."

Debate over national health overhaul legislation has heightened the sense of urgency about primary care and given nurses ammunition for their argument. "The biggest group of clinicians that will be in shortage with universal (insurance) coverage will be those who provide primary care — and that's what nurse practitioners are so extraordinarily good at," says Mary Mundinger, dean of the Columbia University School of Nursing.

There is precedent: Massachusetts' 2008 health insurance overhaul recognized the 5,600 nurse practitioners as primary care providers who would be reimbursed through private insurance and Medicaid at the same rates as doctors. The nurses, however, must work under written protocols that designate a physician who can provide medical direction.

Support For Nurses

Nurse practitioners are gaining support. In a Jan. 14 report, the Center for American Progress, a liberal think tank, said maximizing use of the "entire health care workforce" would also "increase quality while decreasing costs." Ellen-Marie Whelan, senior health policy analyst at the center, said in an interview that nurses "should be part of managing chronic illness, helping a patient navigate the system, helping coordinate among providers."

"The fear that there's a safety concern, I think we just have to look at the evidence, look at the numbers," Whelan said. "Nurse practitioners have been trained to know where their limit is. Since the beginning — now it's been over 40 years — there's just been so much evidence to say that there's nothing to fear and in many cases, there's higher quality."

In September, the nonpartisan Brookings Institution's Engelberg Center for Health Care Reform issued a report by 10 experts that said one way to curb health care spending is to encourage states to permit "greater use of nurse practitioners, pharmacists, physician assistants, and community health workers." Meanwhile, a blue-ribbon committee working under the aegis of the Institute of Medicine and Robert Wood Johnson Foundation is planning to make extensive recommendations later this year on the future of nursing.

Nurse practitioners started out decades ago under close supervision of physicians, with tight restrictions on what they could do. But nurses have successfully pushed state licensing agencies and legislatures to grant them more autonomy and broader duties. The AMA report said, for example, "all states now allow NPs some degree of prescribing privileges," and 12 have granted them authority to prescribe medicine independent of doctor oversight.

This year, several states are considering laws to restrict or expand nurses’ scope of practice. For example, in Colorado, one bill would allow advanced practice nurses in addition to physicians to issue medical orders that direct a patient's care at any facility. Another bill there would eliminate a nurse’s right to declare a patient terminally ill.

Most states require nurse practitioners to obtain a master's degree in nursing, but education and training requirements vary. Cavall, 60, has a master’s, and, prior to becoming a nurse practitioner, she was a registered nurse for several years. She feels very qualified to take care of patients in Tyrrell County. "If you come from a background where you've seen just about everything, that gives you a really good basis for … delivering that care," she says.

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