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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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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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