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December 15,
2008
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IN
THIS ISSUE
Editor's Column:
P4P & PQRI: What Do They Really Mean?
Recovery Audit Contractor (RAC) Put
On Hold
Ron Davis, MD, Tribute Video From AMA
$35 Million Henry Ford Project To Open
Dr. Santucci Selected 'Germany Traveling
Fellow'
WSUSOM News
Flu Vaccination: It's Not Too Late
Dachle To Have Dual Health Care Roles
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Editor's
Column: P4P & PQRI: What Do They Really Mean?
BY
JOSEPH WEISS, MD
Pay-for-performance (P4P) and the Physician Quality Reporting Initiative
(PQRI) are strategies by Medicare and the health insurance companies
to induce doctors to “do the right thing” by paying them to do it.
The “right thing” usually represents a consensus from a group
of experts who cull the literature, review their lecture
notes and discuss among themselves what they think makes
good medical practice. The result is a guideline that Medicare
and insurers use as PQRI measures.
One result of this process is the Osteoporosis PQRI measures
that state that for a physician to qualify for a bonus
in osteoporosis care the physician must have documentation
that answers the following:
- Have 80 percent or more of his/her woman patients ages 60-65
years had at least one DEXA evaluation (a bone-density
measurement) of the spine and femur?
- Have all patients with a diagnosis of osteoporosis had a
DEXA at least once?
- Are all patients with a diagnosis of osteoporosis under therapy
within 12 months of diagnosis?
- Are 80 percent of patients using steroid therapy for more
than three months or who have a fracture history, dx of
hypogonadism, or are on Arimidex or similar anti-estrogen
drug for breast cancer, receiving pharmacologic therapy
for osteoporosis?
- Have 80 percent or more of patients with osteoporosis and
their caregivers received education on Vitamin D exercise
and calcium?
- Have all patients age 50 years of age or older who suffered
a fracture received a DEXA examination and/or started on
therapy to prevent or treat osteoporosis?
- Have all patients with a fracture received counseling on
smoking, drinking , risk fall and safety education?
It is not yet clear what fields a coder must fill in to flag
to Medicare or the gain an insurer’s attention that the
physician has carried through to qualify for the payment.
It is unclear how the physician will be able to remember
all his activities in each patient case to satisfy the
demands of an Osteoporosis PQRI.
What is clear from past experience is that payment by insurers
is erratic and that tracking by a physician’s office is
impossible. Furthermore, while each measure is reasonable,
taken together the groupings are impossible to record.
Estimates are that approximately 38 percent of physicians
who submit for the 2 percent bonuses will receive some
payment; while most physicians believe that they received
less then they had coming.
Physicians can only conclude that that the financial rewards
are not worth the time and cost the reporting requires.
Not only is PQRI an administrative nightmare, but worse,
it is demeaning. We are asked to report in baby steps what
we would do and should do as physicians. We do not need
a lecture nor an incentive to know that any person, man
or woman, who suffers a fracture after a trivial fall,
needs the status of their bone structure assessed. We don’t
need a bonus as an incentive to do what the profession
expects us to do.
Furthermore, we don’t need PQRI to improve our work habits.
In almost all of the specialty re-certifications, the process
requires that the physician undertake a project involving
his or her patients to improve their care. This is the
best way: Physicians working from their practice to advance
patient care with monitoring from colleagues.
Nevertheless, the government, demented and determined, continues
its PQRI initiatives. We can only hope that the federal
fiscal crisis that the sub-prime mess brings, will take
money away from marginal projects such as PQRI. Continuous
improvement is best left with us.
Managing Editor’s Note: The following is a link to the CMS
PQRI website, which contains background information and
news about the program:
http://www.cms.hhs.gov/pqri/
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Recovery
Audit Contractor (RAC) Put On Hold
The
Centers for Medicare & Medicaid Services (CMS) is required
to impose an automatic stay in the contract work of the
four Recovery Audit Contractor (RAC) program. This action
is the result of protests filed by two unsuccessful bidders
for the RAC program with the Government Accountability
office (GAO).
According
the website for The Journal of Oncology Practice, “The purpose
of an RAC is to identify overpayments and underpayments made
by the Medicare program under Part A and Part B. The RACs are
also responsible for the recoupment of overpayments made to
providers.”
An
automatic stay will stop work for all four RAC regional
awards until a determination is made by GAO, as required
under provisions of the Competition and Contracting Act
of 1984 (CICA).
Under
the CICA, GAO has 100 days to issue its decision, which
means a decision would be due for these protests in early
February. The four RAC contracts – and any work under
those contracts – are on hold pending the outcomes of the
protests.
MSMS
will continue to monitor this development and communicate
the results of the protests when the GAO has made their
decision.
The Medicare Prescription Drug Improvement and Modernization Act
of 2003, commonly referred to as the Medicare Modernization Act
(MMA), included a provision that required the Centers for Medicare & Medicaid
Services (CMS) to demonstrate the applicability of
audit contractors to identify overpayments and underpayments, and
recoup overpayments made by the Medicare program. The following questions
and answers are provided to illustrate the CMS initiative of
audit contractors.
According
to The Journal of Oncology Practice, the RAC came about
when, “Section 306 of the MMA specifically directed CMS
to use audit contractors to investigate Medicare
claims. In response to the legislative directive,
CMS developed a three-year demonstration project
for the RAC initiative, which began in March 2005. CMS is
required to evaluate the effectiveness of the initiative and
provide a report to Congress at the end of the demonstration project.”
For
more information about reimbursement issues, contact Stacie
Saylor, CPC, at MSMS at 517-336-5722 or ssaylor@msms.org
For
a full frequently asked questions list on the RAC, visit
the following link to The Journal of Oncology Practice
website:
http://jop.ascopubs.org/cgi/content/full/3/5/255
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Ron
Davis, MD, Tribute Video From The AMA
The
following is a link to a three-minute remembrance of Ron
Davis, MD.
http://www.bigshouldersdubs.com/clients/AMA/23-AMA-Ron_Davis.htm
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$35
Million Henry Ford Project To Open
The
first phase of the two-story, $35-million Henry Ford II
(West) Pavilion expansion project is set to open. The 40
new private rooms have wireless Internet access, patient-controlled
lighting and room temperature, and space for family members
to stay overnight.
The expansion is part of the $310 million investment in the Henry
Ford Hospital Campus. It will house 80 private rooms including 20
intensive care rooms on two floors once complete, bringing the total
number of ICU beds at Henry Ford to 162 - the largest ICU in Detroit.
Phase two of the project is slated to open in the spring of 2009.
In
all, nearly $90 million has been spent in the past two
years, including the expansion and renovation of the Emergency
Department in 2006.
Other
expansion projects include:
- Clinical
Skill Simulation Center - $5 million: This 12,000-square-foot
facility, the largest in the Midwest, has opened at Henry
Ford Hospital allowing health care professionals to practice
and augment their skills using simulations including
computers and mannequins that can simulate hundreds of
different medical conditions. The facility houses two
operating theaters, (one with a $1.6 million da Vinci
robot system), six clinical rooms, a minimally invasive
procedure lab with more than 30 stations, and two classrooms.
Fully-equipped, reconfigurable rooms simulate surgery,
labor and delivery, intensive care, emergency and routine
hospital scenarios.
- Expansion
of existing operating rooms - $10 million: Three new
operating rooms will be added that are designed to accommodate
new technology, including robotics and additional pre-surgery
and recover room capacity.
- Outpatient
tower redevelopment - $33 million: Major redevelopment
and redesign for Oncology, Gastroenterology and Nephrology/Transplant,
Urology and Orthopedics.
- Research & Education
development - $13 million: Expansion and relocation of
a number of labs including Neurology and Neurosurgery,
Hypertension-Vascular, Genetics, Urology, Epidemiology.
- Infrastructure
- $50 million: Redevelopment of the core heating, cooling
along with electrical and emergency power distribution
systems.
- Ongoing
imaging and medical equipment replacement - $120 million
- Routine
renovation and replacement capital - $100 million
Demand
for services downtown has significantly increased in recent
years and is anticipated to grow faster over the next decade.
From 2003 to 2005, Henry Ford Hospital had the highest
admission growth in southeast Michigan, with an increase
of 13.4 percent.
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Dr.
Santucci Selected 'Germany Traveling Fellow'
WCMSSM
member Richard Santucci, MD, has been selected to travel
to Germany as a fellow and will attend a meeting of the
German Surgical Society April 28-May 1, 2009, visit two
German medical centers, he told the Detroit Medical News.
He will give a talk at the meeting he attends. He will
be a visiting professor at health the medical centers,
which are in Heidelberg and Bremen.
Dr.
Santucci is Chief of Urology at Detroit Receiving Hospital,
Specialist-in-Chief at the Detroit Medical Center. He is
also a clinical professor at the Michigan State College
of Medicine.
According
to the Bulletin of the American College of Surgeons, “Dr.
Santucci has researched and written extensively on genitourinary
trauma and reconstruction as well as on more customary
urological topics.”
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WSUSOM
News
Neurology
Leader Helps Draft New Guidelines
The
associate chair of the Wayne State University School of
Medicine’s Department of Neurology played a key role in
creating new guidelines developed to assist in the evaluation
of patients who may suffer from neuropathy.
Richard
A. Lewis MD, professor and associate chair of Neurology
for the School of Medicine, said the guidelines, adopted
by the American Academy of Neurology (AAN), will aid clinicians
in evaluating patients, and provide a more efficient and
complete evaluation.
The
guidelines were published in the Dec. 3, 2008, online issue
of Neurology, the medical journal of the American Academy
of Neurology.
“The
group of clinicians involved in this study represents some
of the most outstanding investigators in clinical peripheral
nerve disease,” Dr. Lewis said. “As the lead author on
the skin biopsy section, I was honored to work with three
outstanding investigators who lead the field in the use
of skin biopsy for clinical and research purposes.”
The new guidelines, according to the AAN, indicate a combination
of blood tests and other assessments appear to be “most helpful” for
tracing the cause of neuropathy, also known as neuritis or distal
symmetric polyneuropathy. The nerve disorder affects one in 50 people
in the general population and one in 12 over the age of 55, according
to the AAN. Symptoms include numbness, tingling or pain, often starting
in the feet and moving to the hands. The most common cause is diabetes,
although heredity, alcohol abuse, poor nutrition and autoimmune processes
can have an effect.
WSUSOM Prof To Oversee Anti-Seizure Medication Trial
The
Wayne State University School of Medicine will participate
in a trial comparing the effectiveness of two FDA-approved
anti-seizure medications and how they are administered
to patients before they arrive at hospitals.
The Rapid Anticonvulsant Medication Prior to Arrival Trial, or RAMPART,
is sponsored by the National Institutes of Health. The purpose of
the study is to determine whether Midazolam or Lorazepam are safer
and more effective at stopping seizures when paramedics are called
to treat a patient whose seizures aren’t stopping.
The study will be conducted on patients transported to and treated
at Detroit Receiving and Sinai-Grace hospitals. Robert Welch, MD,
associate professor of the Department of Emergency Medicine, will
oversee the study. Dr. Welch also serves as associate director of
Clinical Research for the department, as well as principal investigator
of the Wayne State University hub of the Neurological Emergencies
Treatment Trials Network (NETT).
The
network, funded by the National Institutes of Health, includes
more than 100 emergency departments and Emergency Medical
Services agencies in 17 major metropolitan areas. The organization
was formed to conduct large trials to reduce the burden
of injuries and illnesses affecting the brain, spinal cord
and peripheral nervous system. The network, said Dr. Welch,
explores the narrow window of opportunity that seems to
exist in treating neurologic damage from a variety of conditions,
ranging from stroke and traumatic brain injury to seizures
and meningitis. The study of rapid interventions under
study by NETT requires the assistance of paramedics treating
patients in the field.
The
seizures, called status epilepticus, create an emergency
situation, Dr. Welch said. Estimates indicate that between
120,000 and 200,000 cases take place each year in the United
States. As many as 55,000 people die from such seizures.
Complications
of prolonged seizures, Dr. Welch explained, include impaired
ventilation and aspiration into the lungs, which can result
in pneumonia. Other problems include heart rhythm problems
and direct injury to the nervous system.
“Optimal
outcomes in patients, therefore depends on treatments that
lead to rapid cessation of seizure,” Dr. Welch said. “In
the pre-hospital setting, it can be difficult to treat
this group of patients, particularly since starting an
IV to administer medications can be very difficult.”
Dr.
Welch said the study should begin by March 2009 and may
continue for two years. Nationwide, the study may involve
as many as patients, and Dr. Welch expects to oversee “one
of the top enrolling sites.”
Area
residents who suffer a seizure and are treated by Detroit
EMS personnel may be enrolled in the RAMPART trial. Since
the study will involve patients who are severely injured
or severely affected and can’t make decisions for themselves,
the research has been given exception from informed consent
parameters.
For
questions regarding the study, call the RAMPART trial
hotline at 1-866-929-6388.
Researcher
Publishes New
Autism/Schizophrenia
Findings At WSU
A
Wayne State University School of Medicine professor has
published research that could open the gateway for the
exploration of new treatments for autism, schizophrenia
and a host of other neurodegenerative diseases.
Alexander Gow, PhD, associate professor of the Center for Molecular
Medicine and Genetics, the Carman and Ann Adams Department of Pediatrics
and the Department of Neurology, published the paper, “Claudin 11
Stops the Leaks,” in the Dec. 1 issue of the Journal of Cell Biology.
Patients with schizophrenia and other affective disorders are thought
to suffer from brain disconnect –- the different parts of the brain
don’t communicate with each other. Dr. Gow said this can be interpreted
as neurons not sending signals to different parts of the brain or
signals being sent but arriving too late.
While Dr. Gow said the significance of the research in terms of immediately
combating disease and disorders is speculative at this point, the
findings may explain some of the symptoms for a number of neurological
diseases, including autism, schizophrenia and other disorders.
“While our study doesn’t suggest any treatments at this stage, it does suggest
new directions of research that should be looked at in schizophrenia and other
neurodegenerative diseases,” Dr. Gow said.
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Flu
Vaccination: It's Not Too Late
It
is not too late to get a flu shot. Although flu cases have
already been confirmed in Michigan, flu activity often
does not peak until January or later and influenza can
continue to circulate through spring.
More than 84 percent of the United States population is recommended
to get an annual flu vaccine - that's more than 4 out of 5 people.
However, anyone who wants to reduce their chances of getting flu
or of spreading it to a loved one should be vaccinated. The Centers
for Disease Control and Prevention, along with Families Fighting
Flu, have developed a video, entitled Why Flu Vaccination Matters,
to spread the message that flu is a serious disease - one that can
lead to death in otherwise healthy children.
In February, the Advisory Committee on Immunization Practices (ACIP)
voted to expand the recommended ages for annual flu vaccination to
include all children 6 months through 18 years of age.
Another group at heightened risk for the negative complications from
influenza is pregnant women. Expecting mothers have historically
low rates of influenza vaccination. According to a recent study,
a two-for-one protection against the flu develops when an expecting
mother is vaccinated. When a pregnant woman is vaccinated, the unborn
child is protected. Emphasizing the importance of vaccination among
pregnant women, the National Women's Health Resource Center launched
the campaign, Flu Free and a Mom-To-Be.
Pregnant women can receive the flu shot during any trimester of pregnancy.
All new parents, grandparents, siblings, babysitters, and contacts
of infants should be vaccinated against influenza, as well as pertussis
(whooping cough).
The flu vaccine is the single best way to protect against influenza.
Anyone who wants to reduce their chances of getting the flu can get
vaccinated. Visit www.michigan.gov/flu for
the most up-to-date flu information.
Courtnay McFeters, MA
Adolescent Immunization Coordinator
MDCH Division of Immunization
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Daschle
To Have Dual Health Care Roles
Los
Angeles Times Examines
HHS Secretary-Nominee Daschle's Approach to U.S. Health
Care System Overhaul
[Dec 15, 2008]
President-elect Barack Obama's HHS secretary
nominee -- former Senate Majority Leader Tom Daschle (D-S.D.),
who Obama also named as director of a new White House Office
of Health Reform -- "has put a premium on cooperation
between the White House, Congress and major health care
interest groups" in the overhaul of the U.S. health
care system, the Los
Angeles Times reports. The Times examines Daschle's
book on health care called "Critical," and his
specific and "potentially controversial" plans
for health care reform.
Daschle has proposed to establish a Federal Health Board modeled
after the Federal Reserve to determine the medications, medical devices
and other treatments that federal health care programs should cover
based on cost-effectiveness. According to the Times, Daschle
also has proposed a requirement that all U.S. residents obtain health
insurance and the establishment of a public health plan to provide
coverage for those who do not obtain private coverage. The Times also
looks at Daschle's "virtual road map for the kind of campaign
the Obama White House and its allies will probably pursue in their
effort to avoid the pitfalls that doomed" health care reform
efforts by former President Bill Clinton in the 1990s (Levey, Los
Angeles Times, 12/15).
Health
Care 'Czar'
According to the Wall
Street Journal, as director of the White House
Office of Health Reform, Daschle will serve as a "health czar
of sorts" -- one of a number of czars whom Obama has appointed
to address various issues. Obama seeks to "have someone in the
White House with the president's ear to coordinate policy and give
the topic the weight it deserves," and the appointment of a
czar "gives an issue prominence, allows for coordination among
agencies and streamlines decision making," the Journal reports
(Meckler, Wall Street Journal,
12/15).
Daschle will have a role on health care reform that "truly does
represent a czar role," Phil Blando of the health care consulting
group AB+M
Partners said, adding, "He's the go-to guy across the board.
People will try to end run around him, and they're going to have
nowhere to go" (Frates, The
Politico, 12/13).
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