Patient Safety and the Joint Commission

Two of my local hospitals just invested $3 – $4 million dollars in preparation for an inspection of the facilities by the Joint Commission on Accreditation of Hospitals (JCAHO). The cost of the inspection runs in the $10 million dollar range after the preparation costs. The inspection is a high stress situation for the administration because if you fail, or lose your accreditation, the private insurers will void their contract with you and you won’t get paid for the work done.

Medicare through the Center for Medicare Services (CMS) is preferential to JCAHO so much so that they perform 80% of the inspections of hospitals in America. When JCAHO was initially formed it was in response to poor care in small private hospitals in non-urban nonacademic centers. They cleaned that up.

The current version uses up a great deal of money, creating a legion of hospital administrators running around with clipboards and computer tablets without making any meaningful dent in mistakes and outcome results. In a recent study published in the British Medical Journal the outcomes and re-admissions rate for the same problem within 30 days of discharge were compared at hospitals which rely on state surveys of quality and safety as opposed to the JCAHO ten million dollar survey. They found that there was no statistically significant difference.

In a related report hosted by the journal Health Affairs, a review of the 1999 report of the National Academies of Sciences, Engineering and Medicine entitled, “To Err is Human, Building a Safer Health System” was discussed. That controversial report claimed that 44,000 to 98,000 deaths per year occur due to medical errors. They discussed the work of Linda Aiken, PhD, RN, professor and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania. Her research looked at safety at 535 hospitals in four large states between 2005 and 2016. She called the results disappointing noting improvement based on suggestions in the 1999 report in only 21% of the hospitals surveyed and worsening in 7%. Most of her work involved the staffing and role of nurses which is critical to the quality of the care an institution provides.

Staffing or the ratio of patients cared for per nurse per shift is a critical component of safe patient care. Once a nurse on a non-critical care unit is asked to care for more than four patients the time spent at the bedside nursing diminishes. You cannot recognize problems, complications or changes in your patient’s condition if you are not spending time with them.

It seems to me as a clinician caring for patients in the outpatient and inpatient setting for 40 years that the more time nurses get to spend with patients the better the patients do. Maybe it’s time for government to separate the insurer’s ability to pay hospitals and JCAHO accreditation. Maybe the millions of dollars spent per inspection would be better spent on hiring more nurses per shift plus giving them the clerical and technical support they need to spend more time and care for their patients?

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MRI Use in the Detection of Prostate Cancer

As men live longer the likelihood of them developing prostate cancer increases. Some experts estimate that if we biopsied the prostate of every male 80 years old or older, we probably would find prostate cancer present in almost all of them.

The PSA test has been shown to be less valuable than previously thought when discovered because it does not distinguish between an elevated level due to normal prostatic enlargement, infection or the presence of cancer.  When it is elevated due to cancer it cannot predict which tumors are aggressive and require aggressive treatment and which tumors are non-aggressive or indolent and can just be watched.  For this reason, CMS or Medicare and the United States Preventive Task Force are opposed to PSA use as a screening test.

To deal with these issues, Robert K. Nam MD, MSc, chairperson of genitourinary oncology and professor of surgery at Sunnybrook-Health Sciences Centre in Toronto, Canada has published a small preliminary study in the Journal of Urology on the use of MRI (magnetic resonance imaging) to predict the presence of and the aggressive status of prostate cancer disease.

They recruited men who knew they would be undergoing a PSA test, a MRI of the prostate and a prostate biopsy. Their preliminary results show that the MRI was a better predictor of the presence of prostate cancer than the PSA.  It was also felt to identify how aggressive the disease was which influenced treatment options offered. It was additionally felt to be very accurate in identifying when no prostate cancer was present.

Small numbers of patients were entered in this pilot study. A larger randomized controlled study is now in the planning stages to further clarify these initial findings.  At the same time in our community some of the urologists are now ordering MRI scans to elucidate what is causing an elevated PSA in individuals who have a non-diagnostic digital rectal exam and an elevating PSA.

Changes Coming to Medicare Soon

CMS (Center for Medicare Services) is determined to eliminate fee for service medicine. Fee for service medicine is the system where patients see a physician or “provider” for a visit or service and the “physician or provider” bills the patient or Medicare for each service provided.  CMS argues that “providers” are seeing too much volume and providing too many services thus driving up the cost of health care and the percentage of the Gross National Product that healthcare consumes.  To contain costs they have come up with the public relations mantra of the “Triple Aim.”  The triple aim includes improving the global health of the US population while improving quality and reducing overall costs.  The true emphasis is on reducing overall costs!

To reach their goals, CMS is changing the way it pays for health care and services. By 2019, less than three years from now, CMS hopes to pay one flat fee per beneficiary to large health care organizations ( think HMOs) thus fixing their costs. That large organization will then be responsible for providing total care to a local population.   Hospitals and large health care systems have been purchasing physician practices and employing the doctors in organizations known as Accountable Care Organizations (ACO’s). These health systems believe that by employing the doctors they will control their ordering and spending habits and reduce costs to the overall system. They hope to drive an aging private community physician population into early retirement or at least to stop coming to the hospitals to care for their own patients. They still want these patients to come to their hospital for care but want their employed physicians to provide the care.

If you look around the community you will notice that the major hematologic and oncology groups are now owned by Boca Raton Regional Hospital, as is the major surgical group, several cardiology groups and a host of internists and family practitioners.  The hospital has additionally partnered with its contracted emergency room physicians to open numerous walk in clinics in young population centers to capture that business. At the same time that our local regional hospital is purchasing practices and discouraging local private physicians from continuing to practice, they have introduced a residency training program in internal medicine and surgery. By the fall of 2017 we can expect 100 internal medicine physicians and up to 45 surgical physicians fresh out of medical school and beginning their training, to be serving as a cheap physician labor force for Boca Regional Hospital.  The hope is that ultimately, the Charles Schmidt College of Medicine at FAU will attract and develop a clinical faculty worthy of a university and academic medical center that will enhance medical care in our area but until then we will always wonder, as anesthesia puts us to sleep, who actually is performing our surgical procedures?   Additionally one wonders if you become ill with a serious illness, will you be permitted and covered to see the best physician at the best institution for your problem or will you be required to stay in a narrow network of local providers contracted with the local health entity?

If physicians choose not to join a large health system organization as an employee they will be required to be part of a merit based payment system.  Government administrators, employers and private insurers are certain they can define and quantitate “quality care.”  It is unclear whether there is any meaningful evidence of what “quality care” really is.   Quality care will include parameters like patient satisfaction ( if you are not given an antibiotic for your viral illness or a narcotic pain medicine for your injury appropriately based on the illness or injury will the provider be given a low patient satisfaction grade?), did you counsel an obese patient to lose weight?  Did you counsel a tobacco smoker to stop?  Did you intervene to control a patient’s blood pressure?  All the data entry will require the physician to spend time in front of the computer screen checking more boxes and less time in face-to-face patient care.  Computers will need to communicate with each other from the office to the hospital to the lab etc. but it is unclear who will pay for this? At the end of each year the doctors will be required to send all their patient care data electronically to CMS for review.

Many physicians will choose to just leave or “opt out” of the Medicare system. They will contract privately with patients and be able to order tests and studies at approved institutions but they will not be reimbursed by Medicare for their services nor will the patient be reimbursed by Medicare for the cost of those doctors’ visits and services.  In most areas of the country where the population is not overwhelmingly composed of senior citizens 65 years of age or older, doctors have stopped seeing Medicare patients for just this reason. This may become the norm rather than the exception in South Florida as well.

For the moment my concierge practice is not changing anything. We continue to participate in all the CMS quality programs such as Meaningful Use and PQRS , vaccine registry and Eforcse (a controlled substance prescribing data base) despite the cost and time involved just to leave our future options open. I remain committed to giving my patients longer quality visits and following them where possible into the hospital when they need hospital services. As patients and citizens it is urgent that you become familiar with what CMS and the Federal Government are doing with your taxes and health care options and hold them accountable to your wishes!  If you have questions about this give me a call or set up a special time to discuss this face-to face.

Medicare Will Not Pay For Bone Marrow or Umbilical Cord Blood Transplants

Treatment of blood disorders, leukemia and lymphomas today includes the use of life saving transplants of bone marrow from genetically similar donors and use of newborn childrens’ umbilical cord blood containing stem cells.  The National Marrow Donor Program (NMDP), Be the Match, is the organization which operates the national match registry and has worked for the last 30 years to find 13.6 million adult bone marrow volunteer donors and 225,000 units of fetal cord blood for use. The NDMPs relationship with similar organizations across the globe creates a pool of 24.5 million potential marrow donors and 609,000 units of cord blood.

There are people who need these vital products and cannot find a match but, fortunately, that number is declining. The real problem in men and women 65 years of age or older is that outdated Medicare reimbursement policies do not pay for these products and services and the cost is too expensive for many to bear themselves. The Centers for Medicare & Medicaid Services (CMS) has created barriers to Medicare age recipients being covered for these products resulting in financial uncertainty for the patient. The actual cost is beyond the means of most working individuals to bear.

While private insurers cover more than 70 diseases and conditions, Medicare covers less than a dozen.  The US Department of Health and Human Services calculated that almost 20,000 people in the U.S. could benefit from life-saving marrow or cord blood transplant each year but do not receive them because CMS policy does not cover them.   Where Medicare covers the conditions, the rate of reimbursement is often insufficient to cover the costs.  As Baby Boomers become eligible for Medicare the problem will intensify.

Dr Fred LeMaistre, M.D., director of the Sarah Cannon Blood Cancer Network authored an editorial and appeal to the physician community to lobby for better coverage of marrow and cord blood transplants as a life saving measure.

I for one was stunned to realize just how poor the coverage has remained for these services and find it disgraceful that Sarah Palin’s predicted death panels have now materialized in the form of accepted lifesaving technology not being covered after age 65.  If you are as surprised as I am write to your Congressional representatives and demand appropriate reimbursement for bone marrow and cord blood transplants to save lives!

2015 Changes in Medicine for Medicare Patients

CMS, the parent organization for the Medicare program has decided to reduce health care costs. One method for reducing health care costs is to pay a flat bundled fee for services to one entity and let that entity worry about how to pay for all the services and equipment. CMS first venture into this practice in the State of Florida begins shortly with Medicare deciding to pay one flat fee for knee and hip replacements. In our local area they will pay Boca Raton Regional Hospital (BRRH) one time. The hospital is expected to provide physicians, nurses, pharmaceutical goods, the orthopedic appliance (the hip and knee) and all related costs including your postoperative stay in a rehabilitation facility and physical therapy. If a patient has a medical complication of the surgery, or the surgeon needs consultative physician assistance, that too is covered in the bundled fee.

This means that your orthopedic surgeon will either need to be an employee of Boca Raton Regional Hospital or a contracted physician at an agreed upon price for that service. For several years now, CMS has been encouraging hospitals and health care organizations to organize into Accountable Care Organizations (ACO’s) which would receive the bundled payments and distribute them according to a formula they devise internally. The ACO’s have formed in most parts of the country, but Florida remains as a stronghold of fiercely independent physicians primarily in the medical and surgical specialties that are procedure oriented and generate large revenue streams. They have seen hospital systems like Boca Raton Regional Hospital purchase physician practices and try to run them at least twice in the last 25 years. In each case the hospitals lost large sums of money, the practices ran inefficiently and were returned to the physician owners as a means of cutting their losses. Over the last few years, in addition to building many new facilities , BRRH has been buying up local physician practices and employing the doctors in primary care ( Boca Care), hematology oncology ( Lynn Regional Cancer Group), plus their hospitalist service, emergency department physicians ( who additionally staff their community Urgent Care Centers) pathologists , anesthesiologists and others. By accumulating so many of the formerly private physicians’ as employees or contracted help, they were able to change the structure and bylaws of the medical staff rules and regulations and bylaws allowing the hospital administration to effectively eliminate a checks and balances arm of decision making that protected patient and physician interests.

When you enter the hospital for a knee or hip replacement, it is unclear if your personal physician will be paid by Medicare for seeing you if that physician is not a member of the Accountable Care Organization or an employee of the hospital. A non-employed, non-contracted consulting doctor may possibly bill the patient privately for their services but it is unclear whether Medicare will pay the doctor if they accept assignment, or reimburse the patient if they pay privately and submit the receipt to their insurances for reimbursement. CMS plans to bundle payments for 30% of existing conditions by 2017 and over 70% by 2023. These changes are part of the Affordable Care Act or “ObamaCare”.

I will continue to see my patients who need a hip or knee replacement and develop a fair payment option for them. This will apply to any future bundled service CMS implements as well. My patients will continue to be cared for by me! Experienced local physicians have a healthy distrust of the hospital as an employer based on their past track record. Younger physicians coming out of training with large educational debt and a desire to balance their lives by working regular shifts are more willing to accept employment positions and work for the ACO’s. The goal of the Federal Government is to reduce health care spending by fiat rather than by natural market forces. As the Baby Boomers age and develop more chronic conditions and require more care It seems to me that physicians will need to spend more time with these complex patients rather than less time in short conveyor belt type visits being advocated CMS and current health care policy makers. Feel free to contact me if you wish to discuss any of this.

Addendum: “Why You Can Not Find a Doctor to Accept Medicare”

Center for Medicare ServicesOn April 14, 2015 the Senate, having returned from a recess, voted to repeal the SGR initiative thus halting a proposed 21% minimum payment reduction to health care providers (physicians). Under the new legislation sent to President Obama for approval, doctors will receive between a 0.5% to 1% annual increase in reimbursement through 2019. The measure proposes alternative pay structures which are designed to reduce overall health care costs and rate of health care cost growth. They involve paying one large entity which would then dole out pre-negotiated payments to its members delivering the services.

The American Medical Association as well as specialty medical and health groups are hailing this as a major victory for doctors and patients. I see it a bit differently.

Since 1977 the Congress of the United States has held practitioners at loaded gun point always threatening to reduce physician reimbursement without reducing physician costs or bureaucratic burdens in the least. Generations of policy advisors and elected officials have created a level of mistrust and uncertainty between themselves and providers while always painting the health care delivery teams as greedy money craving individuals more interested in their personal gain than the health of their patients. The result is that for years doctors have left the Medicare system and or retired early.

The current annual increase of up to one percent is accompanied by additional bureaucratic requirements having little or nothing to do with the doctor patient relationship. One percent will not keep up with the cost of inflation or the additional costs involved to meet the bureaucratic new requirements of CMS and policy wonks.

To hail this as a victory is like trying to sell Custer’s last stand at the Little Big Horn as a victory for the US Cavalry. The net result will be the destruction of small private practices, the growth of concierge medicine and the growth of enormous conveyor built corporate medical groups where patients are a product not a human individual.

Why You Can Not Find a Physician Who Accepts Medicare

CMSSGR (sustained growth rate) is a policy and law put in place by the U.S. Congress signed into law four Presidential administrations ago and kept in place year after year by our non-creative elected Federal officials. It was designed to keep the costs of health care growth down by reducing payments to providers if they exceeded the health spending budget for the previous fiscal year. The problem is that health care spending has climbed continuously and it has never stayed within the budgetary guidelines legislated by Congress.

After the first year of the law the General Accounting Office noted an 8% increase in health care spending above the budgeted amount. Congress was supposed to reduce health care payments to providers by 8% the next year, but the providers howled about an 8% reduction and the President and the Congress backed down. Instead of a reduction they gave providers a cost of living increase. The GAO showed that the increased spending was not due to physician pay increases or physician generated costs but due to increased usage and expense in areas outside provider control. Every subsequent year since the SGR became law, the Congress has backed down and granted a miniscule increase instead. The difference between what was budgeted and what was actually spent has accumulated from year to year and each subsequent Presidential administration and U.S. Congress has been reluctant to correct the SGR because the monetary difference would appear on their administration’s balance sheet and legacy. That continued until the Affordable Health Care Act (Obama Care) passed and signed into law before anyone who voted on it actually read it, made correcting the SGR part of the law.

On January 1, 2013 the SGR was due to be repealed by Congress and health care providers were due to receive an 18%- 45% reduction in fees for services. Congress kicked the can down the block until January 1, 2014 and again until December 31, 2014 when Obama Care made the reduction mandatory. The last Congress kicked the issue down the road until April 15, 2015. They were supposed to settle the issue before their spring recess but they adjourned for the spring recess with promises of passing new legislation upon their return on Monday April 13, 2015. That was yesterday when Conservative Republicans announced that after two weeks of consideration they had major problems with provisions of the legislation they had agreed to pass before their spring recess. Their delay will go beyond April 15th.

The Centers for Medicare Services or CMS decided simply to not process any bills or make any payments to health care providers until Congress makes up its mind. Since April 1st they have paid no one except themselves. If no legislation is agreed upon by midnight tonight, CMS will begin processing payments to providers retroactively to April 1, 2015 with a minimum 21% reduction in fees compared to the 2014 payment rates. Physicians are reacting just as expected. Many have decided to no longer see Medicare patients. Those that do see Medicare patients will require payment for services by cash or credit card at the time of service with payments up to 115% of the 2014 Medicare allowable rate for that service. Many will leave the Medicare system entirely.

Our office will continue to see Medicare patients at the current time under the existing payment systems and we will give this Congress an opportunity to fix the problem. When we refer you to specialty physicians we have no way of knowing who will be seeing Medicare patients and who will not. We suggest you ask that particular office before your planned visit so there are no surprises at the check in check out window.