late-breaking news from your medical association volume XXI / no. 1 JANUARY 2014
local Independent Doctors restated with Health Law Changes On December 20, 2013, the San Mateo Daily Journal published an article on its front page entitled “Doctors frustrated with health law changes.” The article included comments by SMCMA President Amita Saxena and others expressing frustration with Covered California and the healthcare system. If you didn’t see the article, you can access it online by visiting smdailyjournal.com, navigating to the “Read Archive PDFs” box in the left column, and choosing the 12/20/13 issue.
state California Midwives Prepare for New Independence California licensed midwives will have increased independence and authority in attending births, under a new law that goes into effect in January. Assembly Bill 1308 removed a clause that required all licensed midwives to be supervised by a physician. Licensed midwives had been unable to fulfill that requirement since it went into effect 20 years ago because physicians’ malpractice insurance prohibited them from filling that role. Licensed midwives will now be authorized to operate birth centers without physician supervision and will have increased access to drugs, tests, and medical devices used in their practice.
national Congress Closes In On Permanent SGR Fix The two-year budget deal approved by the Senate in December aims to prevent another government shutdown. It also includes a familiar annual rider–language to avert a steep pay cut to doctors who treat Medicare patients. But this time might be different, with a fix that lasts. After more than a decade of temporary solutions, it appears Congress may be on the verge of permanently solving its persistent problem in the way it makes Medicare payments to doctors. The problem was actually created by Congress itself back in 1997 through a flawed formula called the Sustainable Growth Act (SGR), and every year since 2002, when the formula first began calling for cuts, the SGR has created political and fiscal fits for lawmakers. The agreement contains provisions to replace the 24 percent Medicare physician payment cut scheduled to take effect on January 1 with a 0.5 percent update for three months. This “payment bridge” is intended to allow the Congress time to complete it work in early 2014 on legislation to repeal the SGR.
national GSK Will Stop Paying Doctors to Promote Its Drugs GlaxoSmithKline (GSK), a British pharma, announced that it will no longer pay doctors to promote its products and will stop tying compensation to sales representatives to the number of prescriptions doctors write. The announcement appears to be a first for a major drug company, and it comes at a particularly sensitive time for Glaxo. It is the subject of a bribery investigation in China, where authorities contend the company funneled illegal payments to doctors and government officials in an effort to lift drug sales. For decades, pharmaceutical companies have paid doctors to speak on their behalf at conferences and other meetings of medical professionals, on the assumption that the doctors are most likely to value the advice of trusted peers. The practice, however, has been criticized by those who question whether it unduly influences the information doctors give each other and lead to prescribing drugs inappropriately to patients. All such payments by pharmaceutical companies are to be made public in 2014 under requirements of the Obama administration’s health care law. Glaxo will continue to pay doctors consulting fees for market research. A Glaxo spokesman said that each year the company spends tens of millions of dollars globally on the practice that it is ending, but declined to be more specific. Glaxo reported third quarter sales of $10.1 billion, a one percent rise from the same period a year ago. Will Wonders Never Cease??? British Surgeon Suspended for Branding Initials on Patient’s Liver Simon Bramhall, MD, 48, used an argon plasma beam eletrosurgery unit to mark the male patient’s organ with the letters “SB,” according to published reports. The initials were discovered by another surgeon during a follow-up procedure, which led patient advocates to question whether Dr. Bramhall had made similar markings on other patients as well. Patients should not be used as an autograph book, stated the consumer group. Dr. Bramhall has been a consultant surgeon in the liver unit of Birmingham’s Queen Elizabeth Hospital since 2002. The surgeon has been suspended pending an internal investigation. Colorado Hospital Experiments with Value-Based Insurance A hospital in Colorado, San Luis Valley Regional Medical Center, is conducting a two-year, value-based insurance experiment in which patients pay for procedures considered ineffective or unnecessary. The hospital hopes to guide patients toward solutions that will help them, as opposed to less effective options. The experiment divides procedures into two categories: inexpensive and effective procedures, such as vaccines, and expensive and unnecessary procedures, such as endoscopies for heartburn. The hospital is conducting its experiment with its covered employees and their dependents and will begin analyzing the data in 2014 to determine whether the disincentives were effective and improved patient outcomes. Dietary Supplements May Lead to Drug-Related Liver Injuries The NYT reports that dietary supplements account for nearly 20 percent of drug-related liver injuries reported by hospitals, up from 7 percent a decade ago, according to analysis by a national network of liver specialists. The research includes only the most severe cases of liver damage referred to a representative group of hospitals around the country. The investigators state that they were undercounting the actual number of cases. While any patients recover once they stop taking the supplements and receive treatment, a few require liver transplants or die because of liver failure. Medical Errors Decrease due to Patient Handoff Procedures A recent study, “Rates of Medical Errors and Preventable Adverse Events Among Hospitalized Children Following Implementation of a Resident Handoff Bundle,” reported in JAMA, states that medical errors decreased from 33.8 per 100 admissions, and preventable adverse events decreased from 3.3 per 100 admissions to 1.5 per 100 admissions, following implementation of new patient handoff procedures. You can find the article online at http://jama.jamanetwork.com/article.aspx?articleid=1787406. Dartmouth Atlas Project Report on Pediatric Care According to a new report by the Dartmouth Atlas Project, variations in physician services, hospitalizations, surgeries, imaging and prescriptions show that the medical care children receive is often the result of provider preference and not patient need. Using claims data generated between 2007 and 2010 from an all-payer data set for patients younger than 8 years old in Maine,
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New Hampshire, and Vermont, researchers found wide variations in care for children in those three states. The report states that while there are many examples of excellent care for children, the inconsistency in care across a relatively small geographic region raises troubling questions about whether medical practice patterns reflect the care that infants and children need, or whether they are primarily the result of differences in physician and hospital practice styles. The authors suggest that both physician practice style and a lack of consensus regarding the optimal approach to medication use likely influenced the wide variation in prescribing patterns. The researchers also concluded that variation in the local supply or capacity of healthcare resources may influence the rates of surgical procedures and imaging, stating that pediatric capacity is generally not located where the need is greatest. In New England, physicians responsible for the care of children tend to locate in areas with lower levels of pediatric health risk. Top Three Health Plan Game Changers in 2013 According to HealthLeaders Media, the landscape is changing rapidly for payers. To be successful, insurers must adapt to new reimbursement models and forge new partnerships with providers. According to the report, the health plan game is changing in three key ways: 1.
New competitors. Hospitals and health systems are beginning to launch their own health plans. Some of the new affiliations are directly competing with the likes of Aetna and WellPoint;
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The launch of the Federal Health Insurance Exchange. With millions of uninsured people potentially enrolling in a HIX this year, insurers see the demand for medical care exploding; and
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The rise of private exchanges. These exchanges, created by health plans, brokers, or other groups, offer health plans more freedom than public exchanges in terms of their level of participation and the products they offer. Some employers are using private HIX as a vehicle to transition employees from self-funded plans to defined-contribution models. Aetna is among the insurers developing their own proprietary HIX.
Is There Really a Physician Shortage? According to a recent Rand analysis, projected shortage estimates result from models that forecast future supply of and demand for physicians, largely based on past trends and current practice. Some examples why the Rand analysis differs with such projected concerns are: 1) The standard underlying assumption is that each newly insured individual, under the ACA, will roughly double their demand for care upon becoming insured, however many studies tend to find increases closer to onethird rather than doubling; 2) a recent study in Health Affairs found that the growing use of telehealth techniques, such as virtual office visits and diagnoses, could reduce demand for physicians by 25 percent or more; 3) new models of care, such as the patient-centered medical home and the nurse-managed health center, appear to provide equally effective primary care but with fewer physicians; 4) new research has shown that physicians do an enormous amount of work that can be handled competently by medical assistants, licensed practical nurses, social workers, pharmacists, and others. Proper delegation can further reduce the need for physicians; and 5) the number of active physicians per capita varies by more than a factor of two across states in the U.S. Though health care quality and access surely suffers in some areas, there is little correlation with physician supply overall. Some Airports Permit Smoking E-Cigarettes Indoors Though, fortunately, no airports on the West Coast permit smoking of e-cigarettes indoors, our neighbors in Phoenix and Las Vegas do so. Other airports in the East that permit indoor e-cigarette smoking are Reagan Airport in D.C., North Carolina, Minnesota-St. Paul, and two airports in Florida. So far all other airports in the U.S. ban the use of e-cigarettes. Would You Bid for Patients’ Surgeries? As more and more patients are obtaining coverage under high-deductible plans, shopping around for affordable care will be a priority for them, their employers, and their insurers. A website called MediBid seeks to provide the transparency through which consumers can make economical decisions. The site, created in 2010, grants elective surgery patients who are willing to pay out of pocket the ability to choose from a range of physicians and hospitals bidding, eBay style, to provide the surgery they are seeking. The providers get their business and the patients get the best deal. MediBid says it is facilitated about 1,800 surgeries. MediBid is owed by a physician who seeks to offer transparent pricing.
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medicare Check Physicians with Outsized Billing The Office of the Inspector General recommends increasing scrutiny of physicians who bill the Medicare program out of proportion to their peers. The conclusion was made by the investigative arm of the U.S. Department of Health and Human Services in a report it released last week. OIG reviewed the billings of more than 300 physicians who received at least $3 million apiece from Medicare Part B in 2009. The billings of those doctors represented almost 2 percent of all payments for clinical services made by Medicare Part B in that year. Overall, more than a third of those doctors were flagged for inappropriate billings by Medicare Audit Contractors, or MACs, and zone integrity payment contractors, or ZPICs. A total of 13 of those doctors overbilled Medicare by at least $34 million. Three physicians later lost their licenses to practice medicine as a result of their billing practices, and two were facing criminal charges.
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