June 30, 2008

IN THIS ISSUE

Editor's Column: The Patient-Physician Contract
Bush Admin Holds Medicare Rates...Temporarily
Docs Outraged As Pols Put Insurers Ahead Of Patients
Henry Ford Medical Group CEO Wins Emmy
Is The NPI Crisis Subsiding?
Gingrich Proposal Addresses Health Care Costs
Massachusetts Plan Faces Cost Challenges At One-Year Mark
DEA Publishes Regs On E-Prescribing Controlled Substances

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The Patient-Physician Contract

 By JOSEPH WEISS, MD
The bounty of BCBS has brought us another wonder: the patient-physician contract. If BCBS keeps its timetable, this contract will eventually become a requirement for any physician who signs a BCBS agreement.

The purpose of a patient-physician contract as conceived by BCBS is to make the patient-physician relationship as concrete as a brick wall. The BCBS wording includes phrases such as: “The physician is sympathetic, tactful and understanding.” “The patient acknowledges the physician’s extensive training and difficult profession.” “The patient is compliant.” “The physician provides all the time necessary to provide adequate treatment.” “The patient attempts to participate in healthy habits and lifestyles.”

The contract contains a page-and-a-half of such statements.

The document ends with lines reserved for signatures of both patient and doctor.

The contract is simplistic. It ignores the complexity of the exchange, tone, evaluation and feeling between patient and physician, an interplay that deals with feelings and attitudes not captured by words. Neither BCBS nor any other financial institution should consider itself capable of dictating how patient and physician should live, act, respond and keep faith; let alone order that these actions, at all times, be free of doubts, prejudice or misjudgment.

The BCBS contract is demeaning. Certainly, physicians consider themselves sufficiently mature to view a page-and-a-half primer written in the style of a schoolchild and setting forth behavioral rules as an insult to their training and their status as professionals. Likely, patients will feel the same resentment with the condescending tone BCBS uses to describe the respect and obedience patients must give physicians.

Finally, the the document’s status as a contract is troublesome. Both patient and physician sign the contract. If patients are upset with their physicians, can a breach of contract ensue? In marriage, the contract, with similarities to the BCBS proposal, often brings with it the possibility of a messy divorce case.

In sum, the BCBS patient-physician contract is illogical, belittling and dangerous. BCBS should scrap this idea and focus its thinking on how to provide better service at lower cost.

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Bush Admin Holds Medicare Rates...Temporarily

HHS Secretary Mike Leavitt on Friday said that the agency will maintain the current Medicare payment rate for physicians because Congress was unable to pass legislation to avert a 10.6% cut scheduled to go into effect July 1 before lawmakers left for the Fourth of July recess, the Washington Post reports. According to the Post, congressional aides said the freeze to payment rates could last 10 days (Kane, Washington Post, 6/28).

A House-passed bill (HR 6331) that would block the reduction to physician fees failed by one vote to receive the 60 votes in the Senate required to gain cloture on Thursday. The House had passed the measure by a veto-proof margin earlier last week. The bill is similar to a measure (S 3101) proposed by Senate Finance Committee Chair Max Baucus (D-Mont.) that also failed to receive enough votes to invoke cloture (Kaiser Daily Health Policy Report [1], 6/27).

Leavitt said he intends to "minimize the impact" of the fee reduction, the New York Times reports. According to the Times, CMS officials said Medicare would hold all new claims for 10 days. As a result, physicians would not experience reduced fees "until July 15, at the earliest," Leavitt said (Pear, New York Times, 6/28). According to congressional aides, a 10-day extension would give senators three days after they return on July 7 from their recess to approve legislation to curb the fee reduction, according to congressional aides.

The White House said that President Bush would have vetoed the House measure and that the Finance Committee was close to working out a compromise that would halt the fee reduction without making cuts to Medicare Advantage, which Bush opposes. The House bill would have cut $14 billion in payments to private health insurers under MA over five years. Leavitt said that if lawmakers are unable to pass legislation blocking the fee cut by the end of the extension, he hopes to pay physicians retroactively after the issue is resolved (Washington Post, 6/28).

Senate Majority Leader Harry Reid (D-Nev.) on Friday in a statement said that Democrats will reintroduce the House bill when lawmakers return from the recess (Marcus, Bloomberg/Pittsburgh Post-Gazette, 6/28).

Physician Reaction
Even without the reduction to physician fees, some physicians are debating whether to close their practices, retire early or stop treating Medicare beneficiaries, the Baltimore Sun reports. According to the Sun, doctors in Maryland are also faced with high overhead costs and lower payments from private insurers than elsewhere (Bishop, Baltimore Sun, 6/29). The Pittsburgh Post-Gazette looks at how the "annual dance" over Medicare physician fees affects the ability of doctors to manage their practices. For years -- since the Balanced Budget Act of 1997 -- reductions in fees have been looming for physicians who treat Medicare beneficiaries. However, every year they have been blocked by Congress.

One physician, Melinda Campopiano, said that the prospect that the cuts will not be blocked makes it hard to budget for purchases that would be paid for over many years, such as an electronic health records system. In addition, because private insurers frequently base their payments on Medicare rates, a cut could have a larger effect on physicians, according to the Post-Gazette (Twedt, Pittsburgh Post-Gazette, 6/29).

"Many more physicians will reluctantly retire or reduce clinical practice time," Jack Lewin, CEO of the American College of Cardiology, said, adding, "This hurts access to fragile senior populations" (Abrams, AP/San Francisco Chronicle, 6/30).

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Docs Outraged As Pols Put Insurers Ahead Of Patients

The US Senate has failed to stop drastic payment cuts scheduled for July 1, which puts doctors and patients "on the brink of a Medicare meltdown," says AMA president Nancy H. Neilsen, MD. "The physicians of America are outraged that a group of Republican senators followed the direction of the Bush Administration and voted to protect health insurance companies at the expense of America's seniors, disabled and military families."

Republican senators blocked efforts by Democrats to call up the bill, which was approved June 24 in the House by an overwhelming bipartisan vote of 355 to 59. Michigan physicians have been extremely active at the grassroots level on this issue, and appreciate the stand of Michigan Sens. Debbie Stabenow and Carl Levin, both Democrats, who were among the 59 senators (including nine Republicans) who voted to take up the bill, which would stop the cuts and put patients ahead of partisan politics.

"This intrinsically broken Medicare program simply cannot sustain any more cuts," said MSMS President Michael A. Sandler, MD. "This will create a terrible situation for patients and their doctors. Many physicians will have to make the difficult choice of limiting the number of Medicare patients in their practices."

President Bush had threatened to veto the bill (HR 6331) in part because it would reduce federal payments to private Medicare Advantage plans, offered by insurers like Humana, UnitedHealth and Blue Cross and Blue Shield companies. If passed, the bill would cancel the 10 percent cut scheduled to occur on Tuesday, July 1 and would increase Medicare payments to doctors by 1.1 percent in January.

MSMS, the AMA and other medical societies are strongly urging the Senate to take up the issue again when they return from break on July 6. "The Senate must return from their recess and make seniors' health care their top priority," said Doctor Nielsen. "For doctors, this is not a partisan issue; it's a patient access issue."

MSMS is closely following developments, and encourages members to watch e-mail updates and Medigram for next steps. For further information, contact MSMS Acting Executive Director Julie L. Novak at jnovak@msms.org or 517-336-5768.

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Henry Ford Medical Group CEO Wins Emmy

Mark Kelley, MD, CEO of the Henry Ford Medical Group, was recently awarded an Emmy by the National Academy of Television Arts & Sciences, Michigan Chapter.

Dr. Kelley won for The Minds of Medicine TV show, “Controversies in Preventive Care,” under the Interview/Discussion - Program Special Category.

The show, which aired last November, had Paul W. Smith, morning radio personality for WJR AM 760, and Dr. Kelley discuss the latest science behind prevention recommendations and call on more than half-dozen physicians to offer their opinions. Topics included smoking, diabetes, heart disease, exercise, obesity, blood pressure, diet, alcohol and cholesterol.

Minds of Medicine, is a series of medical shows locally produced in cooperation with WXYZ-TV7 and Henry Ford Health System. Hosted by Paul W. Smith, Minds of Medicine provides an inside look at the doctors and nurses at one of the nation’s top-rated hospitals.

In his role as executive vice president and chief of medical affairs, Dr. Kelley is responsible for leadership of the 1,000-member Henry Ford Medical Group, one of the nation’s largest group practices, and for overall quality within the System

Elizabeth Schnell, director of Brand Management at Henry Ford Health System, was was also awarded an Emmy for her role in the show.

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Is The NPI Crisis Subsiding?

Rejection rates of insurance claims due to NPI problems are gradually returning to normal levels, says Emdeon Business Services, a third-party billing company, as reported in Modern Healthcare. But Medicare is still working to fix problems.

The federal HIPAA law created the NPI to replace a bushel basket of identifiers that doctors and other health care professionals included on claims to third-party payers, including Medicare. On March 1, providers were required to use the NPI for all electronic claims, although they were free to add their old identifiers. But beginning May 23, providers were supposed to submit only the NPI. The old numbers were forbidden.

When May 23 rolled around, problems emerged. Emdeon reported that about one-fourth of the Medicare and Medicaid claims it handled were getting bounced, compared to rejection rates of 6 percent and 4 percent respectively for these programs before May 23. Likewise, rejected Blue Cross claims rose from 3 percent to 6 percent. The failure rate has been attributed in part to the complicated rules governing the NPI and conflicting advice from payers.

However, roughly one month after the NPI-only mandate took effect, rejection rates are settling down, says Miriam Paramore, Emdeon senior vice president of corporate strategy. While rejection rates for some payers are still above the status quo, they are not dramatically so. “Our experience is that it’s trending nicely to the pre-NPI level,” says Paramore, who declined to share exact numbers.

While Medicare has characterized the conversion to the NPI as an overall success, it’s acknowledged that some providers may be experiencing cash flow problems due to rejected claims. Accordingly, it’s announced that it will give hard-pressed providers advance or accelerated payments “where facts and circumstances fall within the scope of the CMS regulations.” Medicare directs such providers to apply for special payments through their Medicare carrier.

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Gingrich Proposal Addresses Health Care Costs

Former House Speaker Newt Gingrich (R-Ga.) this month in Omaha, Neb., outlined a proposal to help reduce health care costs that includes a health insurance mandate for US residents with annual incomes more than $75,000, the AP/Lincoln Journal Star reports.

During a visit to Alegent Health to discuss health care information technology, Gingrich, founder of the Center for Health Transformation, criticized higher-income residents who do not purchase health insurance and seek care in emergency departments. He said that higher-income residents who do not purchase health insurance should have to post bonds to cover the cost of care they might require in the future.

In addition, Gingrich said that he supports federal tax credits to help low-income residents purchase private health insurance. Gingrich also cited the need to encourage residents to seek preventive care to help reduce health care costs. According to Gingrich, adoption of health care IT also can help reduce costs and improve quality of care (Bratton, AP/Lincoln Journal Star, 6/11).

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Massachusetts Plan Faces Cost Challenges At One-Year Mark

One year after the deadline for Massachusetts residents to obtain health coverage under the state's health insurance law, the percentage of uninsured has declined but the law "still faces a huge challenge: costs," USA Today reports. The law requires most state residents to obtain health coverage or face a tax penalty. Since the law was enacted in 2006, the percentage of uninsured Massachusetts adults has decreased from 13% to 7%, according to studies cited by the state. An April study published in the journal Health Affairs found that there are 355,000 newly insured residents in the state. Figures from January show that of the newly insured, 37% are eligible for fully subsidized coverage, 17% are enrolled in an expanded Medicaid program, 14% pay a portion of their coverage, 7% have purchased private coverage without a subsidy and 25% are enrolled in their employer-sponsored plans.

The law was expected to cost about $472 million in the first year, but because of higher-than-expected enrollment in government-sponsored programs, the actual cost was $625 million, according to figures from the Massachusetts Health Insurance Connector Authority. Gov. Deval Patrick (D) has requested $869 million for the program for fiscal year 2009, compared with previous estimates of $725 million.

Costs also have increased for residents. Monthly premiums for partially subsidized coverage increased by an average of 9.4% going into the second year of the program, according to state figures. Premiums for people purchasing private coverage without a subsidy increased by an average of 5.1%.

Jon Kingsdale, executive director of the Connector, said the state's first priority was to expand coverage, and then later address costs. He said, "The way to do this is to make the moral commitment to cover everybody" because it forces "the political leadership, doctors, hospitals and health insurers to grapple with how to make this affordable. I don't know any other way to get America to confront this very tough problem." Kingsdale added that state lawmakers are considering legislation that aims to reduce health care costs through a variety of measures, including increased use of electronic health records.

According to USA Today, as the presidential candidates debate their health care proposals, the Massachusetts health insurance law "is both touted as an example to copy nationally and criticized as a model to avoid." Kaiser Family Foundation President and CEO Drew Altman said, "Some will say it's an overwhelming success story. Others will say it has cost somewhat more than expected, so we can't afford to expand coverage," adding, "The truth is somewhere in the middle" (Appleby, USA Today, 6/30).

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DEA Publishes Regs On E-Prescribing Controlled Substances

The Justice Department’s Drug Enforcement Administration has proposed regulations that would allow physicians to electronically prescribe "controlled" substances such as opiate pain relievers, anabolic steroids and stimulants with the potential for abuse or addiction, according to a news release.

The proposed regulations could help reduce prescription forgery by maintaining a “closed system of controls on controlled-substances dispensing,” according to the agency. E-prescription could potentially provide a means for pharmacists and drug-enforcement officials to trace controlled-substance prescriptions to a legitimate prescriber, and ensure that the medication is being dispensed by the intended pharmacist and received by the intended patient. The regulations also are aimed at reducing paperwork and prescription errors caused by illegible handwriting, according to the news release.

“Our goal is to put in place an electronic-prescribing system that is efficient, medically beneficial to patients and prescribers, and provides security from hackers and others who might seek to engage in fraudulent prescribing activities,” said Joseph Rannazzisi, DEA deputy assistant administrator for the Diversion Control Office.

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