November 6, 2006

Editor's Column:P4P, We're Already Doing It!
Now Is The Time To Fight Medicare Cuts!
Four-Star: Good Intent, Poor Reimbursement
November Is National Diabetes Month
Events Of Interest
The Benefit Of Paying Dues Early
PROM Seeks Specialty Reviewers For Peer Review
Anti-Smoking Contest For Kids
NPI Application

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Editor's Column:
P4P; We're Already Doing It And Doing It Well

By JOSEPH WEISS, MD
The physician community already uses and runs pay-for-performance effectively. Insurance companies and government should not enter this arena.

In Wayne County physician groups such as Wyandotte IPA and the Olympia Medical Services in Garden City put the theories of pay for performance into practice. These physician organizations keep data on medications their doctor participants prescribe each patient including the name of the medicine, whether it is generic or a pharmaceutical brand, and the cost of the medicine. The organization calculates each physician's use of generics, and how that figure compares with others in the group. The profile also includes the use of generics by the whole group and compares usage to other physician organizations in Wayne County, the State of Michigan, and in the US overall.

Each physician in the IPA receives a letter with this information; each physician can see how he or she stands compared with colleagues. A physician who reaches a generic rate of 55 percent in NSAIDs receives a bonus; it can be as high as $5,000. If the physician reaches the same rate in PPIs, that physician can earn another $5,000. If the physician reaches 55 percent in prescribing generic non sedating antihistamines, a third $5,000 bonus is possible.

Seeing how colleagues work combined with the monetary gain possible gives you an incentive to review what you do. Then you can decide if you want to change your practice patterns and to what extent.
The medical community responds best when the drive to change comes from us. Fellow physicians set goals we can understand, and create rewards that are palpable to us.

We should resist outside meddling into pay-for-performance. The way to do it will be in hand when in our hands.

Now Is The Time To Fight Medicare Cuts!

Together, physicians, their spouses and medical group managers are a powerful voice in advocating for organized medicine and for Michigan patients. That is we are asking you to join MSMS in urging the US Congress during its "lame duck" session to stop the scheduled 5.1 percent physician payment cut scheduled to go into effect January 1, 2007.

The Issue - An UN-Sustainable Growth Rate Formula:
" Medicare payment rates are determined by the sustainable growth rate (SGR) formula, which does not accurately reflect the costs that physicians incur when treating Medicare payments because it is based on the gross domestic product rather than increases in medical practice costs. Our work will not be done until the flawed SGR formula is permanently replaced, so this issue does not need to be revisited every year.

Your Help Is Crucial - Take Action NOW:
All it takes is a few clicks of your mouse! Using the online MSMS Action Center (www.msms.org) , you can send a prewritten email to your US Senators and Representatives asking them to stop the cut and to replace the UN-sustainable growth rate formula. Or call them using the AMA Grassroots Hotline: 800-833-6354

If No Action Is Taken:
According to the AMA, from 2007 to 2015, Medicare payments in Michigan will be cut by $8.03 billion. For physicians in Michigan, the average annual cut during this period of time will be $34,000 per year for each physician.

In addition, data from the US Bureau of Labor Statistics show that these Medicare physician payment cuts will have an impact on 87,158 employees in Michigan. (Note: These figures represent the impacts on Medicare physician payment schedule services only, and do not include potential spillover effects from private, Medicaid, TRICARE and other plans that tie payments to Medicare rates. In addition, per-physician impacts may vary considerably within the state depending on each physician's Medicare patient load and utilization.)

For more information, contact MSMS Executive Director Kevin A. Kelly at (517) 336-5742 or kkelly@msms.org.

Four-Star: Good Intent, Poor Reimbursement

By PAUL NATINSKY
The Wayne County Four-Star program offers a wide range of health care benefits to employees earning less than $14 per hour for $56 per month. The program covers primary care, hospitalization, emergency care, outpatient care and pharmaceuticals for employees of small employers who don't receive health insurance through their employer and likely would be uninsured.

Four-Star is a "one-third-share" program in which employees, employers and the program's sponsors split the premium three ways. In addition to Wayne County, St. John Health, the Detroit Medical Center, Henry Ford Health System and Oakwood Healthcare System are program sponsors.

While the program expands access to health insurance for the uninsured, there is a downside: it pays about the same as Medicaid, which, in effect, expands service provision at a rate that fails to cover physician costs of providing care.

"Anything that expands options is a good thing, but you'll forgive us if we're less than enthusiastic about this," said WCMSSM Public Health Committee Chair Daniel Michael.

In his presentation to the committee Four-Star Administrator Richard Nowakowski said the program helps provide coverage for many patients whose only other option would be costly emergency room services.

So far, the program covers about 300 individuals at 62 or 63 programs, well short of its enrollment goals.

"The economy is still a big concern for employers -- we're asking them to spend $600 a year per employee," said Nowakowski. "One Downriver pizza business said business is as bad as it's been in 30 years."

For more information, visit www.waynecountyfourstar.org

November Is National Diabetes Month

Did you know diabetes significantly increases your risk for heart disease? Research shows between 60-80% of patients with diabetes have high blood pressure. Did you know, for people with diabetes, blood pressure control is just as important as controlling sugar level?
Poorly controlled blood pressure can increase complications from diabetes. To avoid complications ask your health care provider a few basic questions:
1. Is my blood pressure near or below 130/80?
2. If not, what medications am I on to control my blood pressure?
(3-4
medications may be necessary)
3. Am I due for my annual lipid-screening (cholesterol) test?
4. In addition to exercising and diet, do I need to be on a medication to help get my "bad cholesterol (LDL)" below 100?

Also, as part of your diabetes self-management plan, make sure you have an annual dilated retinal (eye) exam and ask your doctor to be sure you have at least an annual A1C test (average blood sugar); in most cases
the A1C test should be done 2-4 times per year.

Here at (Insert company name here) we are proud to be aligned with and supporting the Greater Detroit Area Health Council's (GDAHC) Save Lives Save Dollars (SLSD) project. For more information, please go to www.diabetes.org, www.gdahc.org or (List any company specific offerings or websites related to diabetes).

Events Of Interest

MSMS Discusses Pay-for-Performance & More at Michigan Hospitals
As part of its "Making the Rounds" program, the Michigan State Medical Society will be visiting a number of Michigan hospitals and other medical facilities - including the St. Joseph Health System in Tawas City - to discuss current pay for performance initiatives with physicians. The MSMS “Making the Rounds” program is a unique opportunity for hospital-affiliated physicians to meet with MSMS staff and learn about a variety of health care and financial topics, including the following:
· The Future of Medicine Initiative
· Reimbursement Services and Assistance
· Michigan’s Wellness Initiative
· Physician Contracting Pitfalls
· The Michigan Board of Medicine
· Medical Records and the Law
· Ensuring Accurate Billing for Hospital Services
· Preparing for the OIG: Are You Compliant?
· Civics 101: Health Care Legislative and Advocacy Update
· The ABCs of Owning a Business
· Health Savings Accounts
· Michigan Doctors’ Political Action Committee
· The Benefits of MSMS Membership

"Making the Rounds" has been hosted at Crittenden Hospital in Rochester, Oakwood Healthcare System in Annapolis, Mary Free Bed Hospital & Rehab Center in Grand Rapids, Sparrow Health System in Lansing, Bon Secours Hospital in Grosse Pointe, North Ottawa Community Health System in Grand Haven, and Central Michigan Community Hospital in Mt. Pleasant.

Generally, the Making the Rounds program is free. If you are interested in hosting the Making the Rounds program at your facility, contact Pooja Naik at MSMS at (517) 336-5719 or pnaik@msms.org. For additional speakers and topics, please contact Rebecca Blake at (517) 336-5729 or rblake@msms.org.

Group Managers: Save the Date for Third Party Payer Day!
Friday, November 17, Lansing
Sponsored by MSMS, the Michigan Medical Group Management Association, the Michigan Medical Billers Association, and the Michigan Osteopathic Association, Third Party Payer Day features all the major payers of Michigan, who will present expected changes for the coming year, give feedback on how to get claims paid in a timely manner, and answer questions about claims processing and reimbursement.

The Medicaid claims department also will be on hand to meet one-on-one with attendees to discuss problem claims and answer questions. (Bring your Medicaid claims and the remittance advice that had the rejection on it for each claim.)

For details, visit www.michmgma.org
or contact Sherry Barnhart at (517) 336-5786 or sbarnhart@msms.org

The Benefit Of Paying Dues Early

Pay your 2007 Membership Dues by December 31 to receive free CME! Paying your dues in full by December 31, 2006, will enable you to receive one free registration to any MSMS educational program or conference in 2007 (excluding the MSMS Annual Scientific Meeting). Upon receipt of your dues, you’ll receive a coupon for which to use when registering. And don’t forget, up to 86 percent of your dues may be tax-deductible!

PROM Seeks Specialty Reviewers For Peer Review

The Physician’s Review Organization of Michigan (PROM) is now offering packages of focused external peer reviews to assist hospitals and medical offices meet JCAHO. The new bundled review service allows the medical facility to enroll annually and choose the review service package that best meets its needs. In addition, by signing up for a package, medical facilities can save roughly 15 percent off the traditional price of separately scheduled reviews.

The new focused external peer review service encourages routine quality assessment of medical staff members. PROM believes there is a need for prospective clinical quality review to aid in the early identification of variant clinical performance that, if left unattended, may lead to clinical privileging evaluations. By creating a program of focused review that looks for elements that are associated with increased risk of malpractice claims or other institutional complications, organizations will be better equipped to retain their staff members and maintain a high quality of patient care.

PROM has served as the sole peer review body for medical groups, as well as a validating service for those medical facilities with existing peer review boards.

For more information about PROM’s focused external peer review service, contact PROM at (517) 336-1400, (800) 688-1895, or prommail@medadvgrp.com. Also, visit www.peerreviewmi.net.

Seeking Specialists
Due to its considerable growth and demand for review services, the Physician’s Review Organization of Michigan (PROM) is seeking specialists in the fields of hematology/oncology, neurosurgery, and oral surgery.

Since being founded in 1983, PROM has provided thousands of case reviews to a wide range of groups including hospitals, physician practices, managed care organizations, and major insurance companies. PROM recently renewed a five-year contract with Blue Cross Blue Shield of Michigan and began a new relationship with Great Lakes Health Plan.

PROM utilizes the expertise of its experienced staff and over 150 carefully selected reviewers to ensure that clients receive informed, confidential, and objective reviews. PROM is fully accredited by the American Accreditation Health Care Commission.

If you are interested in becoming a reviewer, contact Judy Trotter at PROM at (517) 336-1400, (800) 688-1895, or jtrotter@medadvgrp.com.

Anti-Smoking Contest For Kids

To help kids fight back against tobacco advertising and raise awareness about the dangers of smoking, Henry Ford Health System is co-sponsoring the Southeast Michigan Tobacco Counter-advertising Contest for Kids.

“One of our goals for this program is to help kids better understand the messages in tobacco advertisements so they are better prepared to resist the pressures to smoke,” says Ronald M. Davis, MD, director of Henry Ford’s Center for Health Promotion and Disease Prevention.

The contest is open to students in K-12 throughout southeast Michigan. Students will create an anti-tobacco counter-advertisement either as a poster, computer-generated artwork, radio commercial, song, TV commercial or music video. Each entry should be accompanied by a typed statement describing the work in no more than 350 words.

Every day it is estimated that 4,000 US teenagers try their first cigarette, and another 2,000 become regular smokers. Of those, about half will eventually die from a smoking-related disease.

But the health consequences of smoking are probably the last thing on the minds of teens when they light up. Television, movies and other forms of advertising are influencing kids more than ever these days, and tobacco companies are constantly looking for new ways to get their attention.

Entries can be submitted beginning Monday, Oct. 16 to Amanda Holm, project manager, Henry Ford Health System, 1 Ford Place, Suite 5C, Detroit 48202. Deadline for entries is midnight Wednesday, Nov. 15.

Prizes of $200 and $100 will be awarded for the top two entries in each grade. Schools whose students submit a winning entry will receive $250.

The contest is co-sponsored by the Wayne County Medical Society Foundation, and funded by the Community Foundation of Southeastern Michigan, Blue Cross/Blue Shield of Michigan Foundation, Michigan State Medical Society Foundation, Francis Rhoades Memorial Foundation, Linda Ford and R. Joe Dennis, and Flight Attendant Medical Research Institute.

For more information, contact Holm at (313) 874-3959 or visit www.counteradvertising.com

NPI Application

The National Provider Identifier (NPI) is an Administrative Simplification mandate of HIPAA. The NPI is a 10-digit number that will be used to identify you to your health care partners, including all payers, in all HIPAA standard transactions. The NPI will replace the identifiers you currently use when submitting claims to the various payers.

All health care providers are eligible to receive NPIs. All HIPAA covered health care providers, whether they are individuals or organizations, must obtain an NPI to identify themselves in HIPAA standard transactions.

You can obtain an NPI by applying online at https://nppes.cms.hhs.gov or by calling (800) 465-3203 to request a paper application.

The NPI compliance date is May 23, 2007. However, you should apply for your NPI as soon as possible so you are prepared for testing when the payers are ready.

For more information about the National Provider Identifier, visit http://www.cms.hhs.gov/NationalProvIdentStand/.

This publication brought to you by Natinsky Publishing Network.

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