E-DMN - May 27, 2008

May 27, 2008

Editor's Column: Where In The World Is Michigan's Congressional Delegation?
Six Health Systems Sign On For Proton Beam Consortium
Group Pushes For E-Prescribing Bill Using Existing Standards
Former Legislator Urges Government To Drive Health Care IT
WSUSOM Student Ponders Career Caring For Underserved
'Medical Home' Pilot Features Medicare Pay Bump
Federal Judge Blocks Bush Rule To Reduce Medicaid Payments

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Editor's Column: Where In The World Is Michigan's Congressional Delegation?

By JOSEPH WEISS, MD
Speaking from my personal experience and to others and to others now back from Capitol Hill, the Michigan congressional delegation, both Democrats and Republicans, are seated in their proper places on the issue of physician Medicare reimbursement.

No Michigan senator or congressman believes in continuing the Sustainable Growth Rate (SGR) mandate. Each congressman will give physicians assurances that suspension of the mandate will come by July 1, 2008 and will last 18 months. The congressmen also pledge that physicians will get some increased reimbursement: not to exceed 1.5 percent, though an even more token amount 0.5 percent is possible. Note that the pledge is only to override the SGR for 18 months, not to end it.

If the congressmen are asked what will happen after 18 months, they all give a vague reply. They will say that the purpose of the 18-month override is to give the 2009 Congress ample time to evaluate the ideas bubbling up on alternative indexes and innovative formulas to provide predictable and appropriate reimbursement to physicians.

However, no congressman will predict that a new reimbursement bill will pass during the 2009 congressional session.

In the past, I have offered the opinion that the ritual of physicians to travel to Washington, DC, to plead for funds cannot continue through the millennium. I may be wrong.

It is possible that no matter what the composition of Congress, be it Republican, Democrat, Libertarian or Anarchist, a long-term plan for physician pay is not in sight.

What the medical community can forecast is that in 18 months we will again face the crisis in reimbursement we must deal with today.

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Six Health Systems Sign On For Proton Beam Consortium

A consortium of Michigan health care systems has created a joint venture to bring an emerging cancer treatment to the state's residents. The treatment, called proton beam therapy, is an innovative form of radiation treatment with potential to cause fewer side effects and less damage to healthy tissue compared to traditional radiation.
Six of the state’s largest health systems have agreed to participate in the collaborative, including the state’s only two National Cancer Institute-designated comprehensive cancer centers.
The six health systems that have agreed to the collaborative to date are:
• Ascension Health (Genesys Hurley Cancer Institute)
• Henry Ford Health System
• Karmanos Cancer Center
• McLaren Health Care (the Great Lakes Cancer Institute-McLaren Campus)
• Trinity Health (St. Joseph Mercy Hospital, Ann Arbor)
• University of Michigan Health System
The consortium was formed to mitigate the costs of proton beam therapy – starting with the $160 million needed to build a treatment center. At the same time, a consortium will provide greater economic benefit to Michigan than a single hospital provider, since it will spread an economic benefit across a wide array of providers and communities. In addition, a consortium ensures the state will have one proton beam center operating at high efficiency versus multiple centers operating at low volumes, risking financial and operational viability.
Proton beam therapy is a type of radiation that uses particles called protons, whereas traditional radiation therapy uses photons, or X-rays. Protons deliver radiation to a more targeted area than photons can achieve, which means it has the potential to spare more healthy tissue or organs as the radiation more precisely hits the tumor. Currently, five facilities across the country offer proton beam therapy, with at least a half dozen additional sites planned or proposed.
“Working together as part of a consortium will ensure that proton beam therapy is available to all in Michigan who need it, regardless of where they live or what hospital their insurance covers. This consortium of non-profit hospitals - the trusted source of medical care for Michigan's citizens - is best poised to develop this promising therapy for the state,” says Nancy Schlichting, president and chief executive office of the Henry Ford Health System.
The health systems have already begun working together and are making progress toward a September deadline from the state Certificate of Need Commission to develop a business plan. Specifically:
• Efforts have begun to develop the criteria for and identify a location for the facility.
• The organizations have engaged a consultant to develop a comprehensive business plan for the consortium.
• Representatives from each of the member health systems have begun meeting regularly to ensure plans are finalized in a timely fashion.
• Physicians from the member hospitals will be meeting soon to discuss clinical protocols and research guidelines.
All providers of radiation therapy services in the state of Michigan have been, or will soon be, invited to be part of this consortium. This will ensure the greatest possible access to the most people in the state that are in need of proton beam therapy.
The consortium approach is supported by a large number of providers, purchasers and employers, as well as by the Economic Alliance of Michigan, Michigan Manufacturers Association and the Small Business Association of Michigan.
For more information about Michigan’s proton beam consortium, visit www.protontherapyformichigan.org.

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Group Pushes For E-Prescribing Bill Using Existing Standards

The technical standards necessary to establish a national electronic prescribing system already have been adopted by physicians and pharmacy software companies, according to a letter to lawmakers from a coalition of health care providers, insurance companies, academics and pharmacies, CQ HealthBeat reports. The letter, sent this month and addressed to the "bipartisan leadership of key" Senate and House health care committees, stated that while additional standards could allow for more developed functions and features, "they are by no means preventing any physician, pharmacist or patient from realizing the substantial and measurable benefits associated with e-prescribing today" (Cooley, CQ HealthBeat, 5/23).

The American Medical Association in early May at a forum sponsored by the Brookings Institution's Engelberg Center for Health Care Reform discussed a set of standards that physicians would accept for any e-prescribing requirement under Medicare. Steven Stack, an AMA board member and emergency physician, called on lawmakers to ensure that CMS releases a final rule for e-prescribing standards by the end of 2009. The agency in April issued three standards and intends to release three more. Stack also said that physicians should be permitted at least two years to implement e-prescribing technology before they are subject to Medicare payment reductions and that lawmakers should allow exceptions for physicians with small practices, rural physician offices and emergency cases. AMA also called for the removal of a Drug Enforcement Administration rule that would prohibit e-prescribing of controlled substances (Kaiser Daily Health Policy Report, 5/12).

The letter's authors included SureScripts, WellPoint and the National Association of Chain Drug Stores, CQ HealthBeat reports. Advocates for nationwide implementation of an e-prescribing system say it would benefit the existing system and also help save lives.

Senate Finance Committee Letter
In a separate letter to the Senate Finance Committee, which currently is drafting a Medicare package to address the adoption of e-prescribing by physicians under Medicare, officials from the American College of Cardiology said that e-prescribing is a "necessary tool that will improve patient safety by reducing medical errors, decrease adverse drug events, reduce hospitalizations, improve patient adherence and increase patient satisfaction." The letter urged Congress to move on an "expedited" and "date-certain" time frame for nationwide adoption of an e-prescribing system by the end of 2011 but said lawmakers should allow exceptions for physicians with small practices, rural physician offices and emergency cases.

According to CQ HealthBeat, ACC officials already have asked HHS to develop the final three rules for e-prescribing standards by the end of 2009, in addition to the standards announced last month. Patrick Hope, ACC's legislative policy director, said that initial adoption of the system for Medicare patients will lead to wider adoption. He said, "If you're a practice, you probably wouldn't have one type of system for private payers and one for Medicare, and Medicare being the largest payer" would facilitate a broader acceptance of the technology (CQ HealthBeat, 5/23).

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Former Legislator Urges Government To Drive Health Care IT

There are online tools that "can remember what books you ordered over the last three years," so "why can't your doctor's computer remind him" of the details related to patients' prescription drugs, insurance or other procedures, former Rep. Nancy Johnson (R-Conn.), a senior public policy adviser for Baker Donelson, writes in a Washington Times opinion piece.

According to Johnson, the "technology exists," but the "health care industry has been slow to change." Johnson notes that "[o]nly about 14 percent of doctors and primarily large hospitals use electronic medical records, and most of those don't have systems that can communicate with other caregivers of their mutual patients." She writes that the "result is incomplete patient records and more than 100,000 deaths annually due to medical errors caused by missing patient data, illegible prescriptions and other notes, and faulty memories."

Johnson continues, "Medical technology is advancing rapidly," but "medical communication is still a morass of paper files, Post-It notes, faxes and phone messages" because of a continued dependence on the "old but comfortable habit of keeping paper records." She writes that it is "time for comfort to give way to progress."

Johnson writes, "The US government must take the lead in promoting health IT and its adoption by health care teams nationwide," adding that in addition to "supportive legislation, the government can help by establishing standards for the technology so systems can communicate with each other, providing incentives for health IT use, and using advanced technologies in its own health programs." Johnson concludes, "US health care is sick," and if "it's to get better, it needs health IT" (Johnson, Washington Times, 5/27).

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WSUSOM Student Ponders Career Caring For Underserved

Her medical education and volunteer work in the city of Detroit is leading Erica Huddleston to a career as a family physician dedicated to serving urban areas.

Ms. Huddleston, 25, is a native of Indianapolis, Ind. The second-year student now lives in Detroit. She completed her undergraduate degree at Indiana State University, majoring in Life Science. She then attended a master of science in medical science program at Indiana University/Purdue University Indiana.

Her research internship at Methodist Hospital in Indianapolis led to the March 2007 publication of “Optimal End-Organ Protection for Thoracic and Thoracoabdominal Aortic Aneurysm Repair Using Deep Hypothermic Circulatory Arrest” in The Annals of Thoracic Surgery.

Ms. Huddleston became interested in medicine at an early age.

“As a child, I was always fascinated by the doctor's medical equipment,” she said. “My pediatrician even allowed me to participate in my check-ups and fiddle with the tongue depressors and stethoscope. It was then that I decided that I wanted to be a doctor.”

She began taking part in job shadowing opportunities in a variety of departments. However, it was her experience in a pediatrics ward under the supervision of Dr. Francis Gray at Wishard Hospital, that she became interested in that field.

“Dr. Gray is an African-American woman who opened my eyes to the endless array of opportunities that are available not only for African-Americans, but for women in general,” Ms. Huddelston explained. “Dr. Gray had a special connection with each of her patients. She knew more about their lives than what was listed on the chart; she connected with them on a personal level. Her compassion and love for her career inspired me to want to be able to share that same personal connection with my patients. She showed me that medicine requires so much more than just textbook knowledge.”

Ms. Huddleston quickly knew she belonged at the School of Medicine. “Entering a class of 300 students was a bit intimidating. However, on the first day, I knew that this school was different. The sheer diversity of our class was outstanding, and the warmth and generosity of my fellow classmates has been amazing. I now feel as if I am part a family of talented future physicians.”

Her interest in attending the School of Medicine was piqued more than three years ago when she was informed about the facilities by an undergraduate premedical advisor.

“I soon began to do some of my own research on the school and found that it had many of the qualities that I wanted in my pursuit for higher education,” she said. “Not only was the mission statement in compliance with what I believed was necessary for a solid education and a successful career as a physician, but the diversity of the school and its students also provided a great atmosphere that was not available at other colleges and universities.”

Ms. Huddleston serves as co-coordinator for Covenant House Michigan, a shelter for homeless and at-risk youths that also provides GED and job training. She has also served as a mentor and tutor for the residents for two years. In addition, she works with the YDI Drug Prevention Program to educate elementary school students on the hazards of drugs. She is a member of the Black Medical Association and the PULSE Academy; the Social and Hospitality Committee; the SNMA National Conference Committee; Reach Out to Youth; the High School Apprenticeship Program; and the Health Unit on Davison Avenue Clinic.

Because of her SOM experience in the Detroit community, Ms. Huddleston has decided to continue her medical career in primary care as a family physician serving urban areas.

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'Medical Home' Pilot Features Medicare Pay Bump

Medicare, using its upcoming medical home demonstration project, is preparing to pay participating primary care physicians for the extra work required to manage the care of chronically ill patients. Now an AMA-convened panel has outlined how those additional payments might work, reported the American Medical News.

The law mandating the pilot program required the Centers for Medicare & Medicaid Services to consult the American Medical Association/Specialty Society RVS Update Committee, or RUC, for advice on how to structure payment. The panel on April 29 sent its proposal to the agency. The RUC regularly provides advice to CMS on how to value Medicare services, and the agency often concurs.

The three-year project will operate in up to eight states or regions within states. It is expected to begin paying for medical home activities in January 2010 after recruiting roughly 50 practices per location early next year, according to a CMS official. The goal is to see whether paying more up front for targeted, continuous and coordinated patient-centered care for chronically ill beneficiaries will save Medicare money over time.

If CMS were to take the advice of the committee, physicians would receive a monthly payment for each beneficiary they enroll in the project -- in addition to any regular pay for Medicare services. The program would pay extra monthly amounts to offset the increased costs of additional nurse case managers, liability insurance and electronic medical record systems. Total medical home compensation per physician would run in the thousands of dollars per month.

By paying doctors to work with case managers to coordinate a targeted plan of care for each chronically ill patient, CMS hopes to save money by reducing the amount of complex services and hospitalizations that those beneficiaries will require.

The participating practices will have an incentive to bring down costs. No Medicare payments or medical home fees will be at risk if the effort proves more costly, but 80 percent of any savings Medicare realizes will go back to the practices as a bonus.

CMS, however, should look at more than dollar amounts when determining how well the medical home project worked, RUC Chair William L. Rich III, MD, wrote in a letter accompanying the pay recommendations.

"The RUC strongly encourages the agency to collect clinical, as well as fiscal, endpoints to measure the success of this demonstration project," he stated. Cost savings may not be immediately apparent during the three-year span.

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Federal Judge Blocks Bush Rule To Reduce Medicaid Payments

Judge James Robertson of the U.S. District Court for the District of Columbia on May 23 delayed the implementation of a rule that would shrink Medicaid reimbursements to safety net hospitals and clinics by approzimately $5 billion over the next five years, the AP/Washington Post reports (AP/Washington Post, 5/24).

The case involves a lawsuit filed by a national coalition of hospitals that includes Alameda County Medical Center, the National Association of Public Hospitals and Health Systems, the American Hospital Association and the Association of American Medical Colleges. The rule, which would apply to hospitals funded by local governments, would require that federal Medicaid reimbursements do not exceed the cost of care provided by the facilities. According to the plaintiffs, the rule would limit the ability of the hospitals to offset the cost of care for uninsured patients through higher Medicaid reimbursements. A congressional moratorium on the rule expired on May 25. The lawsuit asked the court to prevent implementation of the rule after the moratorium expires (Kaiser Daily Health Policy Report, 3/12).

According to Robertson, Congress passed the bill that established the moratorium on May 24, 2007, but, before President Bush signed the legislation, HHS Secretary Mike Leavitt "rushed a typo-ridden final rule" to the Office of the Federal Register for publication (AP/Washington Post, 5/24). However, because CMS did not submit a required notification to Congress until May 25, 2007 -- the day that the law took effect -- the rule violated the moratorium, Robertson said (Reichard, CQ HealthBeat, 5/23). In his decision, Robertson wrote, "In this case, the court is asked to decide whether a maneuver by the Executive Branch deliberately designed to outfox a clear directive of Congress was successful. The answer is no" (Russell, San Francisco Chronicle, 5/24).

The decision requires CMS to republish the rule, which would take effect after a 60-day comment period (Rosetta, Salt Lake Tribune, 5/24). The delay allows Congress time to pass a supplemental war appropriations bill (HR 2642) that would extend the moratorium until April 2009 (CQ HealthBeat, 5/23).

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