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October 15, 2007 |
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IN THIS ISSUE
Editor's Column: Proposed Standard For A Disruptive Joint
Commission
Blue
Cross Lawsuit Deadline: Oct. 19
Medicaid ID
Number Format To Change
Michigan Pols Move To Stem
Health Plan Rate Hikes
WSU Psychiatry Prof Earns HIH Grant
Close The Gap
Health Disparities Conference |
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Click Here To Contact Us
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Editor's Column: Proposed Standard For A
Disruptive Joint Commission
By JOSEPH
WEISS, MD
The Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) has issued a new mandate that all hospitals are expected to
meet by Jan. 1, 2008. The new directive deals with the disruptive
physician. The purpose of the standard, LD.3.15, in the words of
JCAHO, is for: “leaders [to] set expectations for behavior among
those who work in the organization.”
JCAHO has attached six elements to its anti-disruptive
mandate:
1. The [hospital] leaders develop a code of conduct that
applies to everyone who works in the organization.
2. The code of conduct defines desirable and disruptive
behavior.
3. All who work in the organization are educated about both
desirable and disruptive behaviors.
4. The leaders develop processes for managing disruptive
behavior.
5. Leaders identify the role of individual leaders in
managing disruptive behavior.
6. Leaders establish a fair hearing process for those who
exhibit disruptive behavior.
The failure to
define “leaders” is troublesome. The JCAHO could have specified that
code of conduct developed by hospital administration be done in
cooperation with the hospital medical staff. JHAHO could have
required that ratification of the disruptive physician standard
depend on a vote of approval by both the hospital medical staff and
the hospital’s board of directors.
Furthermore, LD
3.15 should be accompanied by a sunset rule. A mandate of this
nature, a document regulating physician behavior, should have life
of no more than three years. Then the rule should end. The
disruptive physician standard needs to be reborn again with final
approval once more coming from both medical staff and hospital
board.
This approach
protects the gadfly.
The Michigan
State Medical Society and the AMA should intervene in the matter of
LD.3.15. The state society should alert each hospital medical staff
to actively participate in the formulation of every LD.3.15 element.
The AMA should meet with the JCAHO to let that leadership know our
feelings that this mandate seems intent on regulating physician
behavior and independence.
The paradox of LD
3.15 is that while the Institute of Medicine calls for open
discussion of error, the JCAHO works just as hard to silence
dissent.
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Blue Cross Lawsuit Deadline: Oct. 19
Physicians must
take action by October 19 to participate in the Love vs. Blue Cross
Blue Shield Association settlement. This settlement resulted from a
physician-initiated class action suit alleging that Blue Cross plans
had, among other things, misrepresented or failed to disclose the
use of edits to unilaterally bundle, down code, and/or reject claims
for medically necessary covered services. In addition to the
creation of a settlement fund, several Blues plans will change some
of their business practices, including basing medical necessity
determinations on generally accepted standards of medical practice
and clinical guidelines.
View the Legal
Alert about this issue from MSMS Legal Counsel at
www.msms.org/yp/legal .
Or contact Patty Bokovoy at 517-336-5768 or
pbokovoy@msms.org .
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Medicaid ID Number Format To Change
The Medical
Services Administration (MSA) has announced a change in the
identification number format for beneficiaries enrolled in Medicaid,
Children's Special Health Care Services, Adult Benefits Waiver,
MOMS, Plan First!, and other health care programs administered by
the Michigan Department of Community Health.
As part of the
Michigan Department of Human Service new eligibility determination
and case management system (called "Bridges"), beneficiary
identification (ID) numbers are being reformatted from eight digits
to 10 digits. Use of the new format will begin November 13. After
that date, physicians may be presented mihealth cards with either an
eight-digit or 10-digit number.
It is important
that physicians review their automated claims/accounting systems to
assure they can accommodate the 10-digit number.
Beginning
November 13, physicians should enter a 10-digit beneficiary ID
number when using the beneficiary ID search method for eligibility
verification. (Eight-digit IDs should be entered with two leading
zeroes.) Also, physicians should report a 10-digit beneficiary ID
number for both paper and electronic claim formats. (Eight-digit IDs
should be entered with two leading zeroes.)
For more
information, contact MSA Provider Inquiry at 800-292-2550 or
ProviderSupport@michigan.gov
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Michigan Pols Move To Stem Health Plan Rate Hikes
A bipartisan group of Michigan lawmakers last week proposed four
bills that would block private health insurers from significantly
raising rates during policy renewals, the
Detroit Free Press
reports. The legislation also would relax a requirement that the
not-for-profit, tax-exempt insurer
Blue Cross Blue Shield of Michigan receive approval from the
Michigan Office of Financial and Insurance Services to increase
rates. The insurer would be able to set rates on its own, and
increases would be subject to review if the insurance office found
them to be questionable. State Rep. Virgil Smith (D), chair of the
state
House Insurance Committee, said he hopes to have committee
hearings on the legislation soon. "We want to make insurance fair,"
Smith said.
Opposition
Private insurers opposed to the plan this week formed the Coalition
for Access and Affordability in Michigan to challenge the
legislation. The coalition comprises the
Council for Affordable Health Insurance, the Life Insurance
Association of Michigan,
Aetna,
Assurant,
Humana,
United Healthcare and
HealthMarkets.
BCBS is Michigan's insurer of last resort, and it receives $80
million in state tax breaks for the designation, according to the
Free Press.
Mark Cook, vice president of government affairs at BCBS, said that
private insurers "cherry-pick 25-year-olds" and then "jack up the
rates" if the policyholder develops a health condition. He claims
BCBS ends up with more expensive policyholders and loses money as a
result.
However, Frank Venuto, a legal consultant for United Healthcare,
said private insurers are prohibited by law from dropping coverage
at the time of renewal and that rate increases occur for an entire
class of members, not for individual members. In addition, private
insurers say they cannot take all applicants because they do not
receive the tax breaks BCBS does. BCBS said legislation is needed to
hold down rate increases for individuals who purchase private
insurance.
According to the Detroit
News, BCBS said it is losing millions of dollars on
individual insurance policies and needs rate increases to pay for
the coverage. Critics of the legislation say BCBS should use its
$2.5 billion reserve to offset rate hikes. "We need to make sure
that what comes out of this is good for the consumer, not for the
Blues, and not for the companies we represent," Venuto said (Anstett,
Detroit Free Press,
10/12).
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WSU Psychiatry Prof Earns NIH Grant
Matcheri
S.Keshavan MD., WSU professor of Psychiatry, recently received a
four-year National Institute of Mental Health grant totaling $ 2.65
million dollars beginning this month. The grant includes a
subcontract to University of Michigan. This grant, titled Bipolar
and Schizophrenia Consortium to parse Intermediate Phenotypes
(B-SNIP) is one of 5 sites throughout the US to receive this
initiative; the other sites are the Yale University, University of
Maryland, University of Illinois, and the University of Texas,
Dallas. The main goals of the study are to characterize the
physiological and neuroanatomical endophenotypes, i.e. biomarkers
and their molecular genetic underpinnings in a large, multi-site
series of patients with schizophrenia and bipolar disorder and their
relatives. An understanding of the genetic and neurobiological basis
of these two disorders will eventually help clinicians make better
diagnoses based on the underlying pathophysiology rather than the
current reliance on purely descriptive, clinical measures.
Elucidating the pathophysiology and causation of these disorders
will also lead to more novel, hypothesis-driven treatments.
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Close The Gap
Komen Community
Challenge
Together Let's Save Lives and End Breast Cancer Forever
The Komen
Community Challenge is our way of telling individuals, policymakers,
community leaders, corporations and health care professionals to
recognize breast cancer as the grave crisis that it is, join our
movement and effect change that will close gaps in research, public
policy and access to quality care that cause breast cancer to be
deadlier for some women than others.
Please join
author and television personality, Rene Syler, state and local
policymakers, health care professionals, business and community
leaders, local celebrities and breast cancer survivors and activists
for a community forum to close the gap in Wayne County.
October 23, 2007
6:00 - 8:00 p.m.
Max M. Fisher Music Center
3711 Woodward Avenue
Detroit, Michigan 48201
Please RSVP by
Friday, October 19th at komencommunitychall@yahoo.com or
734-293-4280.
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Health Disparities Conference
President's
Biennial Conference on Health Disparities
Understanding and Unraveling Health Disparities
Thursday,
November 15, 2007
7:45 am to 6:00 pm
McGregor Memorial
Conference Center
Wayne State University
495 W Ferry Mall
Detroit, MI 48202
Wayne State
University and the Center for Urban and African American Health
invites all healthcare professionals and students to submit
abstracts concerning the treatment and prevention of health
disparities to be considered for presentation at the WSU President's
Biennial Conference on Health Disparities.
Conference
Highlights
-Keynote Address:
"Is Vitamin D an Important Cause of Obesity as Well as a Mediator of
Obesity-Related Diseases?"
-Environmental
Influences on Health
-Discussion
Panel: Health System Barriers to Optimal Care for Minority Patients
-Update on Sickle
Cell Disease
-Health Issues in
the Arab American Community
-Health
Disparities Research
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Thoughts on this Article
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