E-DMN - June 16, 2008

June 16, 2008

Editor's Column: Blue Cross And The Double Cross
Henry Ford Hospital, Hurley Medical Form Partnership
DMC Rehabilitation Institute President Retires
AMA Objects To 'Secret Shoppers'
Analysts Weigh In On Health Care IT
MGMS Urges CMS To Go Slow On Stark Changes
Newspapers Highlight Presidential Health Plans

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Editor's Column: Blue Cross And The Double Cross

By JOSEPH WEISS, MD
At the MSMS House of Delegates a quiet meeting in a small conference room unleashed a bombshell with potentially nuclear-like power. The meeting, hosted by BCBS, introduced physicians to a draft of a policy that BCBS plans to implement this October.

The policy states that a physician should not bill for services that are the result of the physician’s error. BCBS used the following examples of services for which the physician should not bill:

Surgery performed on the wrong body part
Surgery performed on the wrong patient
Wrong surgery performed on any patient

Procedures necessitated by error such as retrieval of a sponge left in a surgical wound or a return to the operating room to tie off a blood vessel previously inadequately closed would also come under the no-reimbursement policy.

Their draft did not limit the not-to-bill rule to the examples mentioned. The policy document contained examples of errors but did not delineate that these were the only errors that would come under the not-to-bill rule.

The BCBS approach differs from the approach from the Centers for Medicare and Medicaid Services (CMS). Medicare will not reimburse hospitals for their expense incurred for urinary tract infections, falls, retrieving foreign bodies, etc. However, physicians’ charges are honored. Not so with BCBS, who will not pay the physicians associated with the medical error.

The problem is: When the tactic not paying physicians for medical errors begins, where does this strategy end? The BCBS draft doesn’t state that only surgeons are at risk and only for extreme errors. Rather, BCBS leaves open the possibility that any physician’s supposed error can trigger the not-to-bill rule.

BCBS says this not-to-bill policy arose because of the pressures coming from corporate customers; BCBS states that it intends a limited application of this new rule.

We will know in time whether this BCBS policy will wither from neglect or bring us to a quagmire of doubts, struggles, legal battles and dubious medical practice. Likely, we will not need to wait long to see other carriers create variations of the not-to-bill idea and turn it into a not-to-win rule for physicians.

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Henry Ford Hospital, Hurley Medical Form Partnership

Henry Ford Hospital's Transplant Institute provides kidney transplant services to patients with debilitating kidney disorders in the Flint area under a partnership with Hurley Medical Center.

Under the partnership, Henry Ford's surgeons will evaluate patients for transplantation and coordinate and perform surgery at Henry Ford, while Hurley's nephrologists will continue to manage their patients before and after surgery. Henry Ford also works with other private-practicing referring nephrologists in the Flint area.

The hospitals say the partnership provides patients with clinical excellence and care close to home.

"We welcome the opportunity to partner with Hurley Medical Center in providing an exceptional level of support and coordinated care before, during and following transplantation," says Marwan Abouljoud, MD, director of Henry Ford's Transplant Institute.

"Our patients will continue to receive high quality, convenient care close to home from the Nephrology staff here at Hurley, while receiving the expertise gained from one of the most experienced kidney transplant teams in the country. This is a win-win situation," says Sayed Osama, MD, chairperson and chief of Nephrology at Hurley.

Henry Ford, one of only two multi-organ transplant centers in Michigan, performs heart, kidney, liver, lung, pancreas and bone marrow transplants. More than 2,100 kidney transplants have been performed since the program's inception in 1968.

The Hurley partnership comes one year after Henry Ford opened a liver transplant clinic at the in. Henry Ford specialists evaluate and work with referring physicians in the Kalamazoo area to manage potential liver transplant patients.

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DMC Rehab Institute President Retires

Terry A. Reiley is retiring after nearly 19 years of service to Detroit Medical Center, most recently as president of DMC Rehabilitation Institute of Michigan (RIM). Reiley will officially leave the DMC on July 5. She is retiring to Colorado, where she began her career as a physical therapist. Under her direction for the past eight years, RIM has flourished as one of the leading rehabilitation centers in the nation with ongoing research and innovative treatment practices that exceed conventional standards.

Reiley, who was appointed RIM’s first female president in 2000, presided over a major hospital renovation, the addition of RIM’s Brasza Outpatient and Fitness Center, a new radiology suite, and the world renowned Center for Spinal Cord Injury Recovery.

This year alone, RIM became home to the Mike Utley Center for Human Performance which features a state-of-the-art biofeedback laboratory. RIM also received a $1 million endowment gift from Urban Science, to fund its spinal cord injury programs.

Since joining the DMC, Reiley has served as clinical services administrator and chief operating officer for RIM, as well as president of Michigan Orthopaedic Specialty Hospital in Madison Heights. Reiley holds a master’s degree from Wayne State University and a bachelor’s degree in physical therapy from the University of California, San Francisco Medical Center.
DMC’s Rehabilitation Institute of Michigan is one of the nation’s largest hospitals specializing in physical medicine and rehabilitation. The Institute is home to many innovative programs, including the Southeastern Michigan

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AMA Objects To 'Secret Shoppers'

Using "secret shoppers" to evaluate the way physicians manage relationships with patients could get in the way of providing needed care to actual patients, according to more than 12 doctors who testified before an American Medical Association panel, the Chicago Tribune reports. AMA on Sunday held its annual House of Delegates meeting in Chicago. According to the Tribune, the use of secret shoppers "is becoming part of the consumer health information wave," spurred by insurers, employers, consumers and others seeking to "ensure they are making informed choices about the kind of care and service they will receive."

The group's Council on Ethical and Judicial Affairs has asked that the 565-member House endorse the practice, noting that secret shopper evaluations would focus on professional relationships with patients, not on clinical practices (Japsen, Chicago Tribune, 6/16). AMA information released on Friday stated that secret shoppers would be "individuals hired to act as patients to monitor service quality." It added, "Secret shoppers have been used to evaluate most of the steps of the patient experience, from the ease of making an appointment over the phone, to the environment and flow of patients in the waiting room, to the encounter with the physician" (Snowbeck, "Medical Hotdish," St. Paul Pioneer Press, 6/13).

Rex Greene, a member of the ethics panel, said secret shopper evaluations can "highlight things that we are not aware of that can benefit our practices." He said, "We would like certain parameters where ethically appropriate," adding, "This is a practice-management tool." However, physicians testifying before the panel disagreed.

Howard Chodash, an associate professor of gastroenterology at Southern Illinois University School of Medicine and an AMA delegate, called the practice "grossly unethical." George Anstadt, an AMA delegate representing the American College of Occupational and Environmental Medicine, said, "This goes against the grain of the doctor-patient relationship," adding, "We should use real patients as sources of real information we need about quality of care." The physicians also expressed concerns that information gathered by secret shoppers could be used to cut physician payments or used by trial lawyers in medical malpractice lawsuits.

The proposal could be endorsed, rejected or referred for more study when the AMA House of Delegates votes this week (Chicago Tribune, 6/16).

AMA President
In a speech before the AMA House of Delegates on Saturday, AMA President Ronald Davis, MD, told physicians to "never take away someone's hope" when treating patients with deadly or terminal diseases. Davis, a doctor of preventive medicine, has been diagnosed with stage-4 pancreatic cancer. He said, "I know the survival statistics for someone with stage-4 pancreatic cancer," but "if the five-year survival is 5%, that is not zero. And as someone with relative youth, good functional status, outstanding health care, love and support from family and friends, and a thirst for life that feeds into a strong mind-body connection, then who knows what the future holds for someone in my situation."

Davis also said physicians should take a leading role in advocating healthy lifestyles, better patient information, expansion of health coverage to all U.S. residents and a reduction of medical errors (Japsen, Chicago Tribune, 6/15). Davis added that AMA should support additional federal taxes on tobacco and work to stop Medicare physician payment cuts (Babwin/Johnson, AP/Arizona Republic, 6/15).

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Analysts Weigh In On Health Care IT

Health IT Now! Coalition on Friday at a Capitol Hill briefing asked lawmakers to pass legislation that would subsidize health care providers for the adoption of electronic health records, ensure interoperability among health care information technology platforms and address privacy concerns, CongressDaily reports (CongressDaily, 6/13).

At the briefing, RAND researcher Richard Hillestad cited a study he led that found implementation of an interoperable health care IT system by 90percent of the US health care system would save $80 billion annually after 15 years. He added that preventive care and chronic disease management efforts that use health care IT could prevent 400,000 deaths and add 40 million workdays annually (Wyckoff, CQ HealthBeat, 6/13). Hillestad also said that use of health care IT could prevent more than 2.2 million adverse events related to medications annually (CongressDaily, 6/13).

RAND researcher Allen Fremont said that use of health care IT to collect and sort data could help determine the causes of health care disparities. Health care IT "is, in the short term, about errors," former Rep. Nancy Johnson (R-Conn.), a co-chair of the Health IT Now! Coalition, said, adding, "But in the long run, it's going to increase the intellectual capacity and treatment capability in the American health care system" (CQ HealthBeat, 6/13).

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MGMA Urges CMS To Go Slow On Stark Changes

The Medical Group Management Association has urged the CMS to review the Stark law rules on physician self-referral before the agency implements additional changes.

In its comments about the CMS’ proposed inpatient prospective payment system rule, the Englewood, Colo.-based MGMA—which represents medical group practices and has more than 21,500 members—said the rules named after Rep. Pete Stark (D-Calif.) have become so complex that “even routine business and clinical arrangements now require development and review by high-priced lawyers and consultants,” which, in turn, adds to the cost of practice and leaves groups uncertain about their compliance status.

“Less than five months from the effective date of the long-awaited Phase III Stark rules, groups are now confronted with another set of complex proposals—some with specific regulatory language proposed for amendment and some simply preamble musings on what options for change may be under consideration—dealing with just a few aspects of this hydra-headed monster,” MGMA President and Chief Executive Officer William Jessee wrote in a letter to acting CMS Administrator Kerry Weems.

The purpose of a review would be to simplify administrative responsibilities, according to the MGMA, which said it would “commit its resources” to helping the CMS in the review process.

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Newspapers Highlight Presidential Health Plans

In broader pieces on the economy and taxes, two newspapers recently addressed parts of the health care proposals of presumptive Republican presidential nominee Sen. John McCain (Ariz.) and presumptive Democratic nominee Sen. Barack Obama (Ill.). Summaries appear below.

§ Los Angeles Times: The Times examined how, as the "faltering economy has catapulted to the top of the presidential campaign agenda," McCain and Obama "have both said they want to make health care more affordable" and accessible, but they "have laid out far different paths to achieving these goals." According to the Times, Obama "is calling for government to do more to address the nation's ills," and "McCain is embracing the traditional GOP faith in free-market solutions," a difference that "gives voters a stark choice." The Obama proposal "leans hard on government action to make insurance more affordable and, ultimately, universally available," and the plan would "make coverage mandatory for children, expand federal subsidies for the uninsured and impose new funding requirements on employers," the Times reports. In contrast, "McCain, in his health plan, shuns that infusion of government money and authority" and "instead would rely on market competition to drive down costs," through the establishment of "new tax incentives for individuals to get their own health insurance" and by reducing the "incentives for people to get insurance through their employers," according to the Times (Hook, Los Angeles Times, 6/15).

§ San Francisco Chronicle: The Chronicle examines how Obama and McCain "offer voters a stark if orthodox choice on the economy" and health care. The current "economic situation ... may leave orthodox remedies outdated," as "escalating health care spending for an aging population will pitch the next president into choices not nearly as palatable as either candidate's campaign promises imply," according to the Chronicle. According to the Chronicle, the tax increases that Obama has proposed "would raise $700 billion over a decade," but "that may not cover Obama's other still-vague economic plans, such as expanding health insurance to everyone who needs it." In contrast, McCain has proposed tax reductions that would "reduce revenue by $600 billion over 10 years," a plan that "ignores the government's voracious need for taxes to pay for government health care programs," the Chronicle reports (Lochhead, San Francisco Chronicle, 6/15).

Editorials
Summaries of two recent editorials related to health care in the presidential election appear below.

§ Los Angeles Times: Obama and McCain, despite the current economic downturn and federal budget deficit, "aren't even paying lip service to curbing the deficit" or the cost of entitlement programs, according to a Times editorial. Both "men's campaigns have laid out strategies for addressing the budget problems," but those proposals are "just not that credible," as economists "agree that the rising costs of debt service and entitlements -- particularly retiree benefits and health insurance for the poor -- are at the heart of the problem and that they'll become completely unmanageable within a few decades if left unchecked," the editorial states. According to the editorial, "in the time-honored tradition of presidential campaigns, neither McCain nor Obama has called for curbs on Social Security, Medicare or Medicaid," and both have "made dubious assertions that health care reform would also slow entitlement spending" (Los Angeles Times, 6/15).

§ St. Louis Post-Dispatch: Obama "didn't come to St. Louis to walk the fault line in modern medicine," but "that's essentially what happened" when he visited with heart patients at Barnes-Jewish Hospital last week, according to a Post-Dispatch editorial. The editorial states, "One of those problems" of the "incredible technological prowess of modern medicine" is cost, which was "at the center of Mr. Obama's public remarks and of the Republican response," the editorial continues. According to the editorial, Obama "touted his voluntary national health insurance plan that he said would make care more accessible and affordable to millions of middle-class Americans," a proposal that McCain has "criticized ... as expensive and unwieldy." The editorial states, "Insurance works best when it allows the greatest number of people to pool their risks," which is "why a national health insurance program like Medicare makes sense," but "Obama's plan falls short of that" because the proposal "wouldn't provide universal coverage." However, "his idea of widening the insurance pool and protecting the growing number of families who face economic disaster should serious illness strike is a big step in the right direction," the editorial concludes (St. Louis Post-Dispatch, 6/15).

Opinion Pieces
Summaries of several recent opinion pieces related to health care in the presidential election appear below.

§ David Broder, Washington Post: "Sixteen years after he shook up American politics by launching an impromptu campaign for president, Ross Perot is about to dip a toe back into the public debates" on the cost of entitlement programs and other economic issues, Post columnist Broder writes. Those "who go to http://www.perotcharts.com will find the Dallas billionaire waiting to challenge them on one of his favorite subjects -- the' ruin' he says America is courting with its spendthrift ways," Broder writes, adding, "Perot is not offering any solutions," but "he is clearly pointing to what he says are the culprits, the big entitlements -- Social Security, Medicare and Medicaid." The Web site cites the need to address the cost of entitlement programs, Broder writes, adding, "So far, John McCain and Barack Obama are not doing that" (Broder, Washington Post, 6/15).

§ Sandra Day O'Connor/James Jones, Washington Post: The United States must "consult our young" on the "approaching tsunami of retirement and health care spending ... precipitated by a combination of aging baby boomers and abnormally high health costs," O'Connor, a retired associate justice for the US Supreme Court, and Jones, a former ambassador to Mexico, write in a Post opinion piece. The authors write, "The Government Accountability Office and many, many others have documented the magnitude of the Social Security, Medicare and Medicaid bills that will come due over the next several decades," and the "more troubling outcomes" include "shifting even greater burdens onto the young and endangering the living standards of everyone else in the process." According to the authors, the "larger and more urgent task" than efforts to reduce the cost of Social Security "is health reform." The authors write, "In the interests of effective cost control, Medicare beneficiaries in particular must be prepared to embrace sensible limits on the way their health care is provided," adding, "Halting runaway medical inflation represents a potential victory for all generations" (O'Connor/Jones, Washington Post, 6/16).

§ Ellen Lutch Bender, Boston Globe: "No single reform would do as much to improve the wealth of our nation and the lives of Americans as a comprehensive overhaul of our health care system," Bender, president and CEO of Bender Strategies, writes in a Globe opinion piece. However, the "best chance of swift and major reform may have died with the end" of the campaign of former Democratic presidential candidate Sen. Hillary Rodham Clinton (N.Y.), according to Bender. She adds, "Clinton kept health care on the front burner, promising action in her first term," and, since she suspended her campaign, the issue "has already slipped as the top domestic concern, a position it held earlier in the campaign for the first time since the last Clinton campaign in 1992." Bender writes that Obama and McCain "have reform plans that take divergent paths, neither of which is as comprehensive as Clinton's." She adds, "There are three areas the next president must focus on, and all three must be in balance: making sure every American has health insurance, improving the quality of care and controlling costs" (Bender, Boston Globe, 6/16).

§ Merrill Matthews, Washington Times: "While much of the health care reform debate centers on the 47 million uninsured Americans, there is an equally important subgroup that must be part of the solution -- the uninsurable," Matthews, executive director of the Council for Affordable Health Insurance and a resident scholar with the Institute for Policy Innovation, writes in a Washington Times opinion piece. "What critics almost never say is that very few people are ever denied coverage -- or can be, for that matter" -- as "the vast majority" of US residents receive health insurance through their employers or public programs, Matthews writes. "If an individual can buy health insurance at any time, many would wait until they need health care to buy coverage," which is "one of the reasons ... Clinton wanted to force everyone to buy coverage," according to Matthews. He adds that the "public policy challenge is to find a way to provide coverage to the uninsurable without destroying the individual health insurance market." According to Matthews, the "best solution is to let the health insurance market work for the vast majority of Americans and create a safety net for those who can't get coverage," which is "what ... McCain's 'Guaranteed Access Plan' (GAP) tries to do." He writes, "If we want a market-based health care system, and John McCain apparently does, high-risk pools are the most effective way to address the safety-net problem of the uninsurable," and the "debate should be over how to make the pools better because a heavy-handed government-run system is not a good or affordable alternative" (Matthews, Washington Times, 6/16).

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