You may have wondered how Obamacare pays for medical care for the 20 million+ newly insured. If you don’t understand the incentives and disincentives to hospitals and physicians and get caught in the regulatory quagmire, then you will be the payor!
Using Medicare, here’s an example of how three related concepts determine whether or not Medicare will pay for a hospital admission.
“When you’re put in the hospital, you’re assigned either inpatient status or observation status. You’re assigned inpatient status if you have severe problems that require highly technical, skilled care.
You’re assigned observation status if you’re not sick enough to require inpatient admission, but are too sick to get your care at your doctor’s office. Or, you might be assigned to observation status when the doctors aren’t sure exactly how sick you are. They can observe you in the hospital and make you an inpatient if you become sicker, or let you go home if you get better.
Since observation patients are a type of outpatient, some hospitals have a special observation area or wing of the hospital for their observation patients. But, many hospitals put their observation patients in the same rooms as their inpatients.
If you’re an inpatient, but Medicare or your health insurance company determines that you should have been assigned observation status, it can refuse to pay for the entire inpatient hospital stay. You probably won’t discover this until the hospital has submitted the claim and had it denied by the insurance company weeks or even months after your hospitalization.” (A)
Medicare Readmission Penalties.
“The ACA requires that inpatient prospective payment system hospitals with higher-than-expected readmissions rates will experience decreased Medicare payments for all Medicare discharges.
In fiscal year (FY) 2013, payment penalties were based on hospital readmissions rates within 30 days for heart attack, heart failure and pneumonia. In 2015, CMS will add readmissions for patients undergoing hip or knee replacement, and in 2016, readmissions for patients with chronic obstructive pulmonary disease. CMS is likely to add other measures in the future. (B)
“Practically speaking, increasing the number of physicians involved in a patient’s care creates opportunities for miscommunication and discoordination, particularly at admission and discharge. Gaps between community physicians and hospitalists may result in failures to follow up on test results and treatment recommendations. Moreover, the acute care focus of hospital medicine may not match the need of many patients for effective disease prevention and health promotion. Studies are under way to see whether these pitfalls can be mitigated, but I suspect the inherent tensions will remain fundamentally irresolvable.
From the patient’s point of view, it can be highly disconcerting to discover that the physician who knows you best will not even see you at your moment of greatest need — when you are in the hospital, facing serious illness or injury. Who is better equipped to abide by an incapacitated patient’s preferences or offer counseling on end-of-life care: a physician with whom the patient is well acquainted or one the patient has only just met? The patient–physician relationship is built largely on trust, and levels of trust are usually lower among strangers.” (C)
So it’s just not narrow provider networks, out-of-network penalties, restricted drug formularies…
It’s also steps towards inventing health care reimbursement “derivatives” such as:
REFERENCE PRICING. Reference pricing serves as a reverse deductible. Rather than the patient paying up to a defined limit and then the insurer covering the remainder, the insurer pays up to a defined limit and the patient pays the remainder.
VALUE BASED INSURANCE. “The additional cost when patients choose procedures that research shows are unlikely to help their condition is a key element of ….value-based insurance, the premise of which is that a mix of financial carrots and sticks can steer patients toward medical services that will help them and away from ineffective or unnecessary ones.”
Hospitals and their employed physicians, including hospitalists, look to minimize the risk of reimbursement penalties and maximize reimbursement. PATIENT BEWARE!
(C) August 10, 2016, at NEJM.org. (Richard Gunderman, M.D., Ph.D.)
Sounds great! But with the transformation of health care more and more physicians are “employed” and not in “private practice.”
The Medical Group Management Association reports that more than 50 percent of physicians are now employed by organizations affiliated with health systems. In some specialties, like cardiology, that is closer to 75 percent.
Discussion of employment tend to focus on the pros and cons for the physician.
Briefly they are:
Pros: The check will clear — The security of knowing that you are not at risk for making payroll may be significant. Both staff and physicians are virtually assured of their incomes. • Administrative headaches disappear — The hospital will worry about issues such as human resources, billing and collecting, rent and overhead, and daily operations. • Incomes are often higher — Many physicians do substantially better in an employment arrangement than they did in private practice.
Cons: You aren’t in charge — Regardless of the assurance that “nothing will change,” it does. Policies are set by the employer. Staff knows who writes their checks. You may end up seeing patients that would not have normally be part of your practice. • Compensation can be changed — Nearly all hospitals pay physicians on some form of production-based compensation formula but that does not mean that can’t change. • You may be judged by new metrics — Hospitals are aggressively adopting quality and patient satisfaction measures that are part of the overall compensation plan. • There may be new technology — Even though you have an EHR it might not be their EHR. You may need to go through another conversion. (B)
But how about the patient?
“One potential downside of the employed model is an increase in physician turnover, which can erode continuity of care. Employed physicians may not have the same financial and emotional stake in their practices as do independent physicians, making it relatively easy for them to move on as practice conditions or other opportunities dictate….
..An additional, more subjective concern is the effect of physician employment on the nature of the medical profession. Will physicians be less likely to take ownership of their patients’ health and be fully engaged patient advocates if they are financially beholden to large, corporate organizations? Will medicine cease being a calling and become in effect a trade?” (C)
“…. hospital-physician partnerships can deteriorate when expectations and accountability on both sides are not well defined up front. A physician may enter into one of these relationships expecting secure compensation and a better lifestyle with more sensible hours while the hospital aims to maintain their volume and/or build their market share with proper control. ….. paying close attention to the metrics of success for both parties, and appropriate consideration of the legal aspects of the contract, including exit clauses for both parties, is essential for long-term success.
Another potential advantage of hospital-physician partnerships is delivering a more integrated care experience for patients. “Many patients do not realize that doctors and hospitals are often separate business entities,” he said. “They assume that everyone is working together to provide them a seamless care experience. Being more closely aligned with the hospital can allow a physician to do that.”
Access to better technology and the ability to streamline care are both major advantages to a partnership,….. but “the overall goal has to be to improve quality and reduce costs of care through a more seamless integrated care experience.” (D)
If you are younger your only experience may be with employed physicians. If you are older perhaps you have already have seen changes in the physician-patient relationship from “back in the day.” So it here are some benchmarks to use:
The core elements comprising patient satisfaction include:
◾Expectations: Providing an opportunity for the patient to tell their story.
◾Communication: patient satisfaction increased when members of the healthcare team took the problem seriously, explained information clearly, and tried to understand the patient’s experience, and provided viable options.
◾Control: Patient satisfaction is improved when patients are encouraged to express their ideas, concerns and expectations.
◾Decision-making: Patient satisfaction increased when the importance of their social and mental functioning as much as their physical functioning was acknowledged.
◾Time spent: Patient satisfaction rates improved as the length of the healthcare visit increases.
◾Clinical team: Although it is clear that the patient first concern is their clinician, they also value the team for which the clinician works.
◾Referrals: Patient satisfaction increases when their healthcare team initiates referrals relieving the patient of this responsibility.
◾Continuity of care: Patient satisfaction increases when they receive continuing care from the same healthcare provider(s).
◾Dignity: As expected, patients who are treated with respect and who are invited to partner in their healthcare decisions report greater satisfaction. (E)
After turning on my GPS app to monitor my walking time, pace, distance, and calories burned, I started thinking about how technology can change physician/ patient communication for the better, if used thoughtfully.
For example, an article discussing the stethoscope as a historical artifact, raises the question are our physicians’ early or deferred adopters of advanced diagnostic technology.
“The stethoscope, the iconic device representing medical technology for the past two centuries, may be fading from the scene as physicians start to embrace mobile technology in the form of handheld ultrasound devices and smartphone apps. Newer digital stethoscopes enable doctors to not only listen to heart sounds and record them, but handheld devices provide high-resolution ultrasound that can actually see what’s wrong with the heart. Why do you want to still focus on these heart sounds that provide very indirect information and secondary acoustic events?” (A)
A related question: Do your physicians take full advantage of the scope of uses of their Electronic Medical Record? • Access to patient information, such as diagnoses, allergies, lab results, and medications. •Access to new and past test results among providers in multiple care settings. •Computerized provider order entry. •Computerized decision-support systems to prevent drug interactions and improve compliance with best practices. •Secure electronic communication among providers and patients. •Patient access to health records, disease management tools, and health information resources. •Computerized administration processes, such as scheduling systems. •Standards-based electronic data storage and reporting for patient safety and disease surveillance efforts.” (B)
And next on the horizon: Smart Phones, if used thoughtfully, can facilitate doctor/ patient communication.
“Smartphones already can be used to take blood-pressure readings or even do an electrocardiogram. ECG apps have been approved by the U.S. Food and Drug Administration for consumers and validated in many clinical studies. The apps’ data are immediately analyzed, graphed, displayed on-screen updated with new measurements, stored and (at an individual’s discretion) shared. I thought I’d seen it all in my decades long practice as a cardiologist, but recently, for the first time, I had an ECG emailed to me by a patient, with the subject line, “I’m in atrial fib, now what do I do?” I immediately knew that the world had changed. The patient’s phone hadn’t just recorded the data; it had interpreted it.” (C)
Getting back to weight loss, just-for-fun, here’s an interesting “futuristic” app. (D)
“Our team has created the world’s first handled device able to scan food at a molecular level: the …. Food Sensor. Our technology includes a three-part system: a pocket-sized spectrometer, a cloud-based patented analysis engine, and a mobile app that work together to scan foods, identify calories, macronutrients, allergens, and also provide relevant information such as food fraud, food adulteration and food quality.”
So besides reading these blog posts you can gauge how innovative your physicians in some of the following ways: every Tuesday the New York Times Science section includes health care technology updates; subscribe (usually free) to email newsletters from nationally prominent academic medical centers. “Google” (carefully) about your medical concerns and conditions, and what new diagnostic technology is being used.
My app says I burned 150 calories writing this post!
Some highly acclaimed initiatives to improve access to quality primary health care and reduce cost have proved challenging. Over the past several weeks we have seen several glaring examples – hospitals leaving ACOs, no change in ED use, the uphill strategy to train more primary care physicians, and “whatever happened” to medical homes.
Dartmouth was the national leader in establishing an Accountable Care Organization. “Why Accountable Care? The current health care system, which pays for discrete medical services instead of outcomes, has resulted in fragmented care and fueled enormous growth in health care costs. To create a more sustainable system, we need a new model that holds health systems and providers accountable for the quality of care delivered to patients. By promoting strategic integration and rewards based on quality care, the Accountable Care Organization (ACO) model offers a potential win-win for providers, payers and patients alike.” (A)
The Dartmouth Atlas quickly became the ACO “bible.” “Under the program, primary care physicians are encouraged to join together with other providers to take responsibility for the full continuum of their primary care patients’ care. They must commit to reporting comprehensive measures of the quality and — eventually — outcomes of care. If they are able to improve quality and thereby reduce costs, they will receive a share of the savings achieved. The term “accountable” is intended to mean just that; ACOs should only receive additional payments to the extent that they are demonstrably improving care for their patients.” (B)
Now: “Dartmouth-Hitchcock Medical Center will abandon the Pioneer Accountable Care Organization program, the system confirmed Tuesday, after losing more than $3 million over the past two years in the Centers for Medicare and Medicaid model.” (C)
“Will Medicaid expansion save the country money as people stop using expensive emergency rooms for primary care? Not yet, suggest the latest findings from a landmark study published online Wednesday in the New England Journal of Medicine. The study of Medicaid patients in Oregon who got Medicaid in 2008 found their ER use stayed high two years after they gained the health insurance coverage — even as they also increased their visits to doctors’ offices.” (D) “People covered by Medicaid were more likely to both see a physician at a regular office visit and also go to the emergency room, casting doubt on the idea that people were using health coverage to shift their health care to a primary care doctor.” (E)
“One “hidden” benefit of the Affordable Care Act is its potential to make primary care more accessible. The U.S. has long lagged behind other industrialized countries on primary care—at great cost to our health and our economy. Throughout the legislation are provisions that, if considered together and implemented effectively, will strengthen primary care for all Americans. With stronger primary care, people will be more likely to receive recommended preventive care and timely care for medical problems before they become serious and more costly to treat.” (F)
Well over twenty new medical schools have opened in the last ten years with more in the pipeline. “Many of the schools under development are making a bigger push to educate future primary care physicians, which will be in greater need to improve the quality of medical care and lower costs by keeping patients out of the more expensive hospital setting.” (G)
But in 2013 AARP reported: “Today, the United States is short about 16,000 primary care doctors — the very doctors (family practitioners, internists and pediatricians) who offer the treatments and preventive screenings that save lives and head off expensive emergency room visits and hospitalizations. Why the shortage? It starts with huge medical school debts and ends with a doctor who is often overworked and underpaid. While students may enter medical school wanting to practice primary care medicine, they graduate saddled with heavy debt — $250,000 is not unusual — which prompts them to switch to a more lucrative specialty. The starting salary for a primary care physician is $150,000 to $170,000; a radiologist or gastroenterologist can make two to three times that. Only one in five graduating internal medicine residents plans to go into primary care medicine……” (H)
“The number of primary care physicians is projected to increase from 205,000 FTEs in 2010 to 220,800 FTEs in 2020, an 8-percent increase. The total demand for primary care physicians is projected to grow by 28,700, from 212,500 FTEs in 2010 to 241,200 FTEs in 2020, a 14-percent increase. Without changes to how primary care is delivered, the growth in primary care physician supply will not be adequate to meet demand in 2020, with a projected shortage of 20,400physicians. While this deficit is not as large as has been found in prior studies, the projected shortage of primary care physicians is still significant.” (I)
The “medical home” was the moon shot to improve access to primary care. “The medical home is best described as a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. It has become a widely accepted model for how primary care should be organized and delivered throughout the health care system, and is a philosophy of health care delivery that encourages providers and care teams to meet patients where they are, from the most simple to the most complex conditions. It is a place where patients are treated with respect, dignity, and compassion, and enable strong and trusting relationships with providers and staff. Above all, the medical home is not a final destination instead, it is a model for achieving primary care excellence so that care is received in the right place, at the right time, and in the manner that best suits a patient’s needs.” (J) “Medical home” has fallen off the innovation radar.
Some extreme, perhaps patient “unfriendly,” options to think about:
VALUE BASED INSURANCE. “The additional cost when patients choose procedures that research shows are unlikely to help their condition is a key element of ….value-based insurance, the premise of which is that a mix of financial carrots and sticks can steer patients toward medical services that will help them and away from ineffective or unnecessary ones.” (K)
REFERENCE PRICING. “Reference pricing serves as a reverse deductible. Rather than the patient paying up to a defined limit and then the insurer covering the remainder, the insurer pays up to a defined limit and the patient pays the remainder. This has the remarkable feature of exposing the patient to the variation in prices for treatments that are above deductible thresholds. And the patient’s contribution isn’t limited by an annual out-of-pocket maximum. “(L)
Perhaps we can do better! by rewarding evidenced based care, rather than outpatient visits.
Back in the 1990s while I was President & CEO of LibertyHealth/ Jersey City Medical Center (a teaching hospital affiliated with Mount Sinai School of Medicine), a neighboring community purchased a linear accelerator and declared itself a Cancer Center, including signs on the New Jersey Turnpike saying “exit here” for cancer care.
And I remember when a friend with possible breast cancer was about to pick a breast surgeon who was in-network (though we didn’t use that terminology then) rather than one based on credentials, hospital affiliations, and experience.
With increasing frequency community hospitals market their cancer centers.
The information below can help you evaluate and weigh cancer care options!
The “gold standard”! National Cancer Institute Designated Cancer Centers.
“The NCI Cancer Centers Program is one of the anchors of the nation’s cancer research effort. There are currently 69 NCI-Designated Cancer Centers, located in 35 states and the District of Columbia, that form the backbone of NCI’s programs for studying and controlling cancer. At any given time, hundreds of research studies are under way at the cancer centers, ranging from basic laboratory research to clinical assessments of new treatments. Many of these studies are collaborative and may involve several cancer centers, as well as other partners in industry and the community.” (A)
To find an NCI Designated Cancer Center click on http://www.cancer.gov/research/nci-role/cancer-centers/find
“Accreditation by the Commission on Cancer (CoC), a quality program of the American College of Surgeons, demonstrates a cancer program’s commitment to providing high-quality, multidisciplinary, patient-centered cancer care.
CoC accreditation is nationally recognized by organizations, including the National Cancer Institute, Centers for Medicare & Medicaid Services, National Quality Forum, American Cancer Society, and The Joint Commission, as having established data-driven performance measures for the provision of quality cancer care.” (B)
There are 9 CoC designations. Comprehensive Community Cancer Program (CCCP).Community Cancer Program (CCP) .Academic Comprehensive Cancer Program (ACAD). Integrated Network Cancer Program (INCP). Veterans Affairs Cancer Program (VACP). NCI-Designated Comprehensive Cancer Center Program (NCIP). Pediatric Cancer Program (PCP). Hospital Associate Cancer Program (HACP). Free Standing Cancer Center Program (FCCP). (C)
Comprehensive Community Cancer Program (CCCP). Accessions more than 500 or more newly diagnosed cancer cases each year. Full range of diagnostic and treatment services provided either on-site or by referral. Participates in cancer-related clinical research either by enrolling patients in cancer-related clinical trials or by referring patients for enrollment at another facility or through a physician’s office. Training resident physicians is optional.
Community Cancer Program (CCP). Accessions more than 100 but fewer than 500 newly diagnosed cancer cases each year. Full range of diagnostic and treatment services provided, but referral for a portion of diagnosis or treatment may occur. Participates in cancer-related clinical research either by enrolling patients in cancer-related clinical trials or by referring patients for enrollment at another facility or through a physician’s office. Training resident physicians is optional.
Academic Comprehensive Cancer Program (ACAD).Provides postgraduate medical education in at least four program areas, including internal medicine and general surgery. Accessions more than 500 newly diagnosed cancer cases each year. Full range of diagnostic and treatment services either on-site or by referral. Participates in cancer-related clinical research either by enrolling patients in cancer-related clinical trials or by referring patients for enrollment at another facility or through a physician’s office.
Hospital Associate Cancer Program (HACP). Accessions 100 or fewer newly diagnosed cancer cases each year. Limited range of diagnostic and treatment services available on-site. Other services are available by referral. Clinical research is not required. Training resident physicians is optional.
Free Standing Cancer Center Program (FCCP). Facility is a non–hospital-based program and offers at least one cancer-related treatment modality. Full range of diagnostic and treatment services is available by referral. Referral to CoC-accredited cancer program(s) is preferred. Participation in cancer-related clinical research is encouraged but not required. Patients may be enrolled in cancer-related clinical trials either at the facility or by referring patients for enrollment at another facility or through a physician’s office. Training resident physicians is optional. No minimum caseload requirement for this category.
To find a CoC accredited cancer program click on https://www.facs.org/search/cancer-programs
Finally, there is an ongoing debate whether or not Cancer Hospitals have better outcomes than hospitals that have cancer programs as part of a broader array of clinical activity.
Perhaps not unsurprisingly studies done by Cancer Hospitals suggest better outcomes in cancer specialty hospitals. (D) (E) For example, one states: “In our analysis, we also show large and persistent risk-adjusted differences in cancer treatment outcomes associated with the type of treating hospital. The findings suggest that compared with community hospitals, survival appears to be superior for patients treated at PPS-exempt cancer hospitals, at NCI-designated cancer centers, and at academic teaching hospitals—all findings consistent with prior reports……..”(F)
Yet a 2014 article notes: “…..in cancer there are lots of metrics, but no settled-on methodology for measuring treatment performance and comparing treatment outcomes between institutions, care settings, or providers. (G)
Some resources to consider:
– National Cancer Institute. How To Find a Doctor or Treatment Facility If You Have Cancer. Click on http://www.cancer.gov/about-cancer/managing-care/services/doctor-facility-fact-sheet
– The American Cancer Society How to Choose a Hospital: Worksheet. Click on http://www.cancer.org/acs/groups/cid/documents/webcontent/003292-pdf.pdf
– Choosing Your Cancer Treatment Hospital. How can you tell a good cancer treatment hospital from a mediocre one? Click on http://www.webmd.com/cancer/features/choosing-your-cancer-treatment-hospital
In an emergency, your life may depend on getting to the nearest hospital. When you can, plan ahead, you and your doctor should discuss which hospital will best meet your health care needs.” (A)
“Identifying a better hospital on your own may be conceptually simple, but in practice it’s not so easy. (Obviously, this is something you’d want to consider in advance of an emergency like a heart attack.)” (B)
Sometimes the best way to start is by determining where not to go and then focusing on a group of possible appropriate hospitals.
Stories like this one, as a first step, can help you decide which hospitals to avoid.
“A few years ago a friend punctured her hand with a BBQ skewer. So she went to the nearest ER.
She was triaged and escorted to a treatment room. Then sat there for 45 minutes because the desk never told the doctor she was waiting, even though the ER had a computerized patient tracking system. A COMMUNICATIONS FAILURE.
While standing at the treatment room door, trying to remind the staff he was there, she overheard doctors talking about other patients’ clinical information. A HIPPA (CONFIDENTIALITY) VIOLATION.
A tetanus shot was ordered by the doctor, but it took another 45 minutes for the nurse to show up. A SYSTEMS PROBLEM.
When asked if she had washed her hand, the nurse said she always washed her hands after each patient. A PATIENT SAFETY ISSUE.
An email sent to the CEO got a “form letter” response addressed to the wrong last name. A PUBLIC RELATIONS PROBLEM.
Two weeks later when she touched the punctured area a splinter popped out. When this information was emailed to the ER Director the email response was “A splinter?! After reading the note and talking to the physician, I was under the impression that the wound was from a “barbeque skewer”. I guess it was not really clarified in the note whether it was metal or wood. I suppose I was just thinking that it was metal.” A CHARTING OMMISSION & A MEDICAL ERROR. AND AN OUTRAGEOUS STATEMENT TO PUT IN WRITING!”
“It’s still a good idea to check the quality ratings and consult with your doctor about where you’ll get the best care — and not be put off if it means driving a bit farther. It could save your life.” (B)
Here’s a link to “Steps to Choosing a Hospital Checklist”. https://www.medicare.gov/Pubs/pdf/10181.pdf (pages 7-10).
Most pregnant women with Zika will eventually wind up at academic medical centers for prenatal care and delivery by a perinatologist, with newborn care provided by a comprehensive team of pediatrician sub-specialists including neonatologists and pediatric neurologists. The earlier during the pregnancy the better!
Highlights from August’s Emergency Preparedness Coordinating Council
Kevin Chason, DO, of the Mount Sinai Health System, shared how his system uses the emergency management structure to coordinate preparedness and response to Zika virus. A multidisciplinary team co-led by representatives from the emergency management and infection control departments has been meeting regularly since May. Key focus areas are patient communication, provider guidance, tracking and monitoring of specimens, and staff safety.
Zika continues to infiltrate US, 20 babies born with Zika-related birth defects
Twenty babies in the U.S. have been born with Zika-related birth defects and 749 pregnant women have lab evidence of possible Zika infection as of Sept. 15, according to the CDC’s most recent update.
There are 3,358 people in the U.S. with the mosquito-born and sexually transmitted virus in the U.S. as of Sept. 21. Of those, 28 people were infected via sexual contact.
Additionally, the CDC reported 43 of the total cases were acquired from mosquitoes in Florida. However, the Florida Department of Health lists its number of locally acquired Zika cases at 92 as of Sept. 22.
Doctors Brace for Zika Babies
This month, the first group of babies in Puerto Rico known to have been exposed to the Zika virus in their first trimester are being born. Pediatricians do not know what to expect.
“This is not like any other outbreak or epidemic,” said Dr. Fernando Ysern, a pediatrician in Caguas, Puerto Rico, who is the president of the Puerto Rico chapter of the American Academy of Pediatrics.
In the pediatric field, Zika looms as a kind of developmental doomsday virus, attacking the vulnerability of early brain development, striking at the neurological basis of human potential. While Puerto Rico, a United States territory, will experience the first wave of children affected by Zika, the rest of the United States is bracing for the spread of the virus.