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ACC rates hospitals’ performance on med prescribing at discharge
The American College of Cardiology is releasing hospital performance data to help patients and caregivers make informed choices about where to go for cardiac procedures.
The first element of the database, found online at FindYourHeartaHome.org, examines a hospital’s performance in prescribing appropriate medication at discharge. Participation in the performance data program is voluntary.
In its Nov. 3, announcement, the ACC noted that there are guidelines in place for appropriate medication for patients who receive an implantable cardioverter defibrillator or undergo percutaneous coronary intervention to help protect against further complications. While the guidelines are followed most of the time, there can be variations in treatment. Hospitals are rated on a four-star scale based on their performance in providing evidence-based care.
“Our hope is that by tracking and publicly reporting these measures, we can raise awareness of variation where it exists and help to ensure consistent, evidence-based care is provided across the United States,” ACC President Kim Allan Williams Sr., M.D., said in a statement. Hospitals volunteering data for public dissemination “are showing a true commitment to quality improvement and helping to ensure heart disease patients nationwide receive the best possible care.”
Participating hospitals release discharge medication data from the National Cardiovascular Data Registry’s ICD Registry and CathPCI Registry. All data are anonymous.
The American College of Cardiology is releasing hospital performance data to help patients and caregivers make informed choices about where to go for cardiac procedures.
The first element of the database, found online at FindYourHeartaHome.org, examines a hospital’s performance in prescribing appropriate medication at discharge. Participation in the performance data program is voluntary.
In its Nov. 3, announcement, the ACC noted that there are guidelines in place for appropriate medication for patients who receive an implantable cardioverter defibrillator or undergo percutaneous coronary intervention to help protect against further complications. While the guidelines are followed most of the time, there can be variations in treatment. Hospitals are rated on a four-star scale based on their performance in providing evidence-based care.
“Our hope is that by tracking and publicly reporting these measures, we can raise awareness of variation where it exists and help to ensure consistent, evidence-based care is provided across the United States,” ACC President Kim Allan Williams Sr., M.D., said in a statement. Hospitals volunteering data for public dissemination “are showing a true commitment to quality improvement and helping to ensure heart disease patients nationwide receive the best possible care.”
Participating hospitals release discharge medication data from the National Cardiovascular Data Registry’s ICD Registry and CathPCI Registry. All data are anonymous.
The American College of Cardiology is releasing hospital performance data to help patients and caregivers make informed choices about where to go for cardiac procedures.
The first element of the database, found online at FindYourHeartaHome.org, examines a hospital’s performance in prescribing appropriate medication at discharge. Participation in the performance data program is voluntary.
In its Nov. 3, announcement, the ACC noted that there are guidelines in place for appropriate medication for patients who receive an implantable cardioverter defibrillator or undergo percutaneous coronary intervention to help protect against further complications. While the guidelines are followed most of the time, there can be variations in treatment. Hospitals are rated on a four-star scale based on their performance in providing evidence-based care.
“Our hope is that by tracking and publicly reporting these measures, we can raise awareness of variation where it exists and help to ensure consistent, evidence-based care is provided across the United States,” ACC President Kim Allan Williams Sr., M.D., said in a statement. Hospitals volunteering data for public dissemination “are showing a true commitment to quality improvement and helping to ensure heart disease patients nationwide receive the best possible care.”
Participating hospitals release discharge medication data from the National Cardiovascular Data Registry’s ICD Registry and CathPCI Registry. All data are anonymous.
Cautious optimism greets Medicare’s revised two-midnight hospital rule
The Centers for Medicare and Medicaid Services finalized a proposal to add more flexibility in reimbursing hospital stays under Medicare Part A if they do not cross the two-midnight threshold, a move that was met with cautious optimism.
“Hospitals appreciate the certainty that stays of at least two midnights are inpatient, with stays of less than two midnights also considered inpatient based on physician judgment,” American Hospital Association Executive Vice President Tom Nickels said in a statement.
For hospital stays for which physicians expect the patient will need fewer than two midnights of hospital care, an inpatient admission may still be payable under Medicare Part A on a case-by-case basis based on the admitting physician’s judgment, according to the final rule.
In addition, the agency does not plan to send recovery audit contractors (RACs) after doctors suspected of violating the two-midnight rule. Instead, CMS plans to use Beneficiary and Family Centered Care Quality Improvement Organizations to conduct initial medical reviews of claims for short-stay inpatient admissions. The claim reviews will focus on educating physicians and hospitals about the policy for inpatient admissions.
Only physicians with questionable practice patterns, such as high rates of claims denial after medical review, will be referred to auditors, according to CMS.
“We look forward to working with the [Quality Improvement Organizations] – which are not paid on a contingency fee basis like those bounty-hunter RACs – and to more fair auditing process,” Mr. Nickels added.
How the QIOs review claims is the part that will be closely monitored by stakeholders.
“CMS finalized the changes that were proposed, which are consistent with what the AAMC has been asking the agency to do,” the Association of American Medical Colleges said in a statement. “AAMC believes it is important that CMS monitor the QIO audits to ensure that they are working as anticipated, and that the QIOs audits do not produce the myriad of problems that the RAC audits produced.”
Even with the cautious optimism, there remains a sense that the new rule does not go far enough.
“Despite ongoing concerns with observation policy overall, we appreciate CMS’ efforts to modify the two-midnight rule to address widespread concerns and issues identified by the provider community, and SHM stands ready to help make it work,” the Society of Hospital Medicine said in a statement.
The organization called for further changes in response to CMS’ initial proposal for the increased flexibility. Those suggested changes included a revised definition of inpatient care to include all time spent in the hospital, better guidance on how audits will be conducted, more concrete guidance on short inpatient stays to minimize claims denials, and better alignment between hours spent in the hospital and the midnights crossed as part of a stay.
“SHM does not believe the two-midnight rule is the optimal policy for addressing the structural issues associated with observation status payment policy,” the organization noted. “However, we recognize this policy and the changes contained in the final rule were enacted with the goal of simplifying the inpatient admission decision, reducing the number of long hospital stays under observation status, and to strengthen deference to physician judgment.”
The Centers for Medicare and Medicaid Services finalized a proposal to add more flexibility in reimbursing hospital stays under Medicare Part A if they do not cross the two-midnight threshold, a move that was met with cautious optimism.
“Hospitals appreciate the certainty that stays of at least two midnights are inpatient, with stays of less than two midnights also considered inpatient based on physician judgment,” American Hospital Association Executive Vice President Tom Nickels said in a statement.
For hospital stays for which physicians expect the patient will need fewer than two midnights of hospital care, an inpatient admission may still be payable under Medicare Part A on a case-by-case basis based on the admitting physician’s judgment, according to the final rule.
In addition, the agency does not plan to send recovery audit contractors (RACs) after doctors suspected of violating the two-midnight rule. Instead, CMS plans to use Beneficiary and Family Centered Care Quality Improvement Organizations to conduct initial medical reviews of claims for short-stay inpatient admissions. The claim reviews will focus on educating physicians and hospitals about the policy for inpatient admissions.
Only physicians with questionable practice patterns, such as high rates of claims denial after medical review, will be referred to auditors, according to CMS.
“We look forward to working with the [Quality Improvement Organizations] – which are not paid on a contingency fee basis like those bounty-hunter RACs – and to more fair auditing process,” Mr. Nickels added.
How the QIOs review claims is the part that will be closely monitored by stakeholders.
“CMS finalized the changes that were proposed, which are consistent with what the AAMC has been asking the agency to do,” the Association of American Medical Colleges said in a statement. “AAMC believes it is important that CMS monitor the QIO audits to ensure that they are working as anticipated, and that the QIOs audits do not produce the myriad of problems that the RAC audits produced.”
Even with the cautious optimism, there remains a sense that the new rule does not go far enough.
“Despite ongoing concerns with observation policy overall, we appreciate CMS’ efforts to modify the two-midnight rule to address widespread concerns and issues identified by the provider community, and SHM stands ready to help make it work,” the Society of Hospital Medicine said in a statement.
The organization called for further changes in response to CMS’ initial proposal for the increased flexibility. Those suggested changes included a revised definition of inpatient care to include all time spent in the hospital, better guidance on how audits will be conducted, more concrete guidance on short inpatient stays to minimize claims denials, and better alignment between hours spent in the hospital and the midnights crossed as part of a stay.
“SHM does not believe the two-midnight rule is the optimal policy for addressing the structural issues associated with observation status payment policy,” the organization noted. “However, we recognize this policy and the changes contained in the final rule were enacted with the goal of simplifying the inpatient admission decision, reducing the number of long hospital stays under observation status, and to strengthen deference to physician judgment.”
The Centers for Medicare and Medicaid Services finalized a proposal to add more flexibility in reimbursing hospital stays under Medicare Part A if they do not cross the two-midnight threshold, a move that was met with cautious optimism.
“Hospitals appreciate the certainty that stays of at least two midnights are inpatient, with stays of less than two midnights also considered inpatient based on physician judgment,” American Hospital Association Executive Vice President Tom Nickels said in a statement.
For hospital stays for which physicians expect the patient will need fewer than two midnights of hospital care, an inpatient admission may still be payable under Medicare Part A on a case-by-case basis based on the admitting physician’s judgment, according to the final rule.
In addition, the agency does not plan to send recovery audit contractors (RACs) after doctors suspected of violating the two-midnight rule. Instead, CMS plans to use Beneficiary and Family Centered Care Quality Improvement Organizations to conduct initial medical reviews of claims for short-stay inpatient admissions. The claim reviews will focus on educating physicians and hospitals about the policy for inpatient admissions.
Only physicians with questionable practice patterns, such as high rates of claims denial after medical review, will be referred to auditors, according to CMS.
“We look forward to working with the [Quality Improvement Organizations] – which are not paid on a contingency fee basis like those bounty-hunter RACs – and to more fair auditing process,” Mr. Nickels added.
How the QIOs review claims is the part that will be closely monitored by stakeholders.
“CMS finalized the changes that were proposed, which are consistent with what the AAMC has been asking the agency to do,” the Association of American Medical Colleges said in a statement. “AAMC believes it is important that CMS monitor the QIO audits to ensure that they are working as anticipated, and that the QIOs audits do not produce the myriad of problems that the RAC audits produced.”
Even with the cautious optimism, there remains a sense that the new rule does not go far enough.
“Despite ongoing concerns with observation policy overall, we appreciate CMS’ efforts to modify the two-midnight rule to address widespread concerns and issues identified by the provider community, and SHM stands ready to help make it work,” the Society of Hospital Medicine said in a statement.
The organization called for further changes in response to CMS’ initial proposal for the increased flexibility. Those suggested changes included a revised definition of inpatient care to include all time spent in the hospital, better guidance on how audits will be conducted, more concrete guidance on short inpatient stays to minimize claims denials, and better alignment between hours spent in the hospital and the midnights crossed as part of a stay.
“SHM does not believe the two-midnight rule is the optimal policy for addressing the structural issues associated with observation status payment policy,” the organization noted. “However, we recognize this policy and the changes contained in the final rule were enacted with the goal of simplifying the inpatient admission decision, reducing the number of long hospital stays under observation status, and to strengthen deference to physician judgment.”
On post-call day, physicians’ reaction time, simple cognitive tasks suffer
SAN DIEGO – If you feel sleepy and out of sorts on a post-call day, compared with a normal work day, you’re not alone.
Anesthesiology faculty reported significant increases in feeling irritable, jittery, and sleepy, along with significant decreases in feeling confident, energetic, and talkative following an on-call period, according to a study presented at the annual meeting of the American Society of Anesthesiologists.
To date, most studies of partial sleep deprivation in health care settings have focused on residents and interns, and less on medical faculty, said lead study author Dr. Haleh Saadat of the department of anesthesiology and pain medicine at Nationwide Children’s Hospital in Columbus, Ohio. “Our call is 17 hours, from 3 p.m. to 7 a.m.; but the call period at most hospitals is 24 hours, and even longer at some private practices,” she said in an interview.
To examine the effects of partial sleep deprivation on reaction time, simple cognitive skills , and mood status in 21 anesthesiologists, Dr. Saadat and her associates obtained verbal consent from the study participants and measured reaction time, mood states, and eight subjective behavioral characteristics at two different time points: between 6:30 a.m. and 8 a.m. on a regular noncall day of work, and between 6:30 a.m. and 8 a.m. after an overnight call (a shift that runs from 3 p.m. to 7 a.m.). The behavioral characteristics included feeling alert, energetic, anxious, confident, irritable, jittery/nervous, sleepy, and talkative, and the researchers used paired t-tests to compare variable means between regular sleep days and post-call days.
Reaction time decreased in all 21 subjects after night call, indicating worse performance (P = 0.047), while total mood disturbance was significantly higher on post-call days, relative to noncall days (P less than 0.001).
Of the 21 anesthesiologists, 19 completed all simple cognitive task questions at both time points and reported significant increases in several of these parameters on post-call days, compared with normal work days.
Post-call observations found participants feeling more irritable, confident, energetic, sleepy (P less than .001), feeling more jittery (P = .003), and feeling less talkative (P less than .001) than on normal work days.
Coping strategies used to address their sleep deprivation were measured as well, with “most of our subjects using problem solving, followed by seeking social support and avoidance,” Dr. Saadat noted. “People who used avoidance had greater declines in reaction time on post-call days, compared with the rest of the study participants. It didn’t matter whether you were male, female, younger, or older.”
Dr. Saadat called for additional studies to evaluate the neurocognitive impact of partial sleep deprivation on physicians’ on-call duties.
“I would like to see if we can replicate the results in bigger centers,” she said. “If this is what is happening, we may need to pay more attention to faculty’s work hours in both academic and private practice settings – not only among anesthesiologists, but also in other specialties. These observations require a closer look at the potential implications for patients’ and professionals’ safety.”
The researchers reported no financial disclosures.
SAN DIEGO – If you feel sleepy and out of sorts on a post-call day, compared with a normal work day, you’re not alone.
Anesthesiology faculty reported significant increases in feeling irritable, jittery, and sleepy, along with significant decreases in feeling confident, energetic, and talkative following an on-call period, according to a study presented at the annual meeting of the American Society of Anesthesiologists.
To date, most studies of partial sleep deprivation in health care settings have focused on residents and interns, and less on medical faculty, said lead study author Dr. Haleh Saadat of the department of anesthesiology and pain medicine at Nationwide Children’s Hospital in Columbus, Ohio. “Our call is 17 hours, from 3 p.m. to 7 a.m.; but the call period at most hospitals is 24 hours, and even longer at some private practices,” she said in an interview.
To examine the effects of partial sleep deprivation on reaction time, simple cognitive skills , and mood status in 21 anesthesiologists, Dr. Saadat and her associates obtained verbal consent from the study participants and measured reaction time, mood states, and eight subjective behavioral characteristics at two different time points: between 6:30 a.m. and 8 a.m. on a regular noncall day of work, and between 6:30 a.m. and 8 a.m. after an overnight call (a shift that runs from 3 p.m. to 7 a.m.). The behavioral characteristics included feeling alert, energetic, anxious, confident, irritable, jittery/nervous, sleepy, and talkative, and the researchers used paired t-tests to compare variable means between regular sleep days and post-call days.
Reaction time decreased in all 21 subjects after night call, indicating worse performance (P = 0.047), while total mood disturbance was significantly higher on post-call days, relative to noncall days (P less than 0.001).
Of the 21 anesthesiologists, 19 completed all simple cognitive task questions at both time points and reported significant increases in several of these parameters on post-call days, compared with normal work days.
Post-call observations found participants feeling more irritable, confident, energetic, sleepy (P less than .001), feeling more jittery (P = .003), and feeling less talkative (P less than .001) than on normal work days.
Coping strategies used to address their sleep deprivation were measured as well, with “most of our subjects using problem solving, followed by seeking social support and avoidance,” Dr. Saadat noted. “People who used avoidance had greater declines in reaction time on post-call days, compared with the rest of the study participants. It didn’t matter whether you were male, female, younger, or older.”
Dr. Saadat called for additional studies to evaluate the neurocognitive impact of partial sleep deprivation on physicians’ on-call duties.
“I would like to see if we can replicate the results in bigger centers,” she said. “If this is what is happening, we may need to pay more attention to faculty’s work hours in both academic and private practice settings – not only among anesthesiologists, but also in other specialties. These observations require a closer look at the potential implications for patients’ and professionals’ safety.”
The researchers reported no financial disclosures.
SAN DIEGO – If you feel sleepy and out of sorts on a post-call day, compared with a normal work day, you’re not alone.
Anesthesiology faculty reported significant increases in feeling irritable, jittery, and sleepy, along with significant decreases in feeling confident, energetic, and talkative following an on-call period, according to a study presented at the annual meeting of the American Society of Anesthesiologists.
To date, most studies of partial sleep deprivation in health care settings have focused on residents and interns, and less on medical faculty, said lead study author Dr. Haleh Saadat of the department of anesthesiology and pain medicine at Nationwide Children’s Hospital in Columbus, Ohio. “Our call is 17 hours, from 3 p.m. to 7 a.m.; but the call period at most hospitals is 24 hours, and even longer at some private practices,” she said in an interview.
To examine the effects of partial sleep deprivation on reaction time, simple cognitive skills , and mood status in 21 anesthesiologists, Dr. Saadat and her associates obtained verbal consent from the study participants and measured reaction time, mood states, and eight subjective behavioral characteristics at two different time points: between 6:30 a.m. and 8 a.m. on a regular noncall day of work, and between 6:30 a.m. and 8 a.m. after an overnight call (a shift that runs from 3 p.m. to 7 a.m.). The behavioral characteristics included feeling alert, energetic, anxious, confident, irritable, jittery/nervous, sleepy, and talkative, and the researchers used paired t-tests to compare variable means between regular sleep days and post-call days.
Reaction time decreased in all 21 subjects after night call, indicating worse performance (P = 0.047), while total mood disturbance was significantly higher on post-call days, relative to noncall days (P less than 0.001).
Of the 21 anesthesiologists, 19 completed all simple cognitive task questions at both time points and reported significant increases in several of these parameters on post-call days, compared with normal work days.
Post-call observations found participants feeling more irritable, confident, energetic, sleepy (P less than .001), feeling more jittery (P = .003), and feeling less talkative (P less than .001) than on normal work days.
Coping strategies used to address their sleep deprivation were measured as well, with “most of our subjects using problem solving, followed by seeking social support and avoidance,” Dr. Saadat noted. “People who used avoidance had greater declines in reaction time on post-call days, compared with the rest of the study participants. It didn’t matter whether you were male, female, younger, or older.”
Dr. Saadat called for additional studies to evaluate the neurocognitive impact of partial sleep deprivation on physicians’ on-call duties.
“I would like to see if we can replicate the results in bigger centers,” she said. “If this is what is happening, we may need to pay more attention to faculty’s work hours in both academic and private practice settings – not only among anesthesiologists, but also in other specialties. These observations require a closer look at the potential implications for patients’ and professionals’ safety.”
The researchers reported no financial disclosures.
AT THE ASA ANNUAL MEETING
Key clinical point: Partial sleep deprivation can adversely impact a physician’s performance on a post-call day.
Major finding: Reaction time decreased in all 21 subjects after night call, indicating worse performance (P = .047), while total mood disturbance was significantly higher on post-call days, relative to noncall days (P less than .001).
Data source: A study of 21 anesthesiologists who were queried about the effects of partial sleep deprivation on reaction time, simple cognitive skills, and mood status.
Disclosures: The researchers reported having no financial disclosures.
Supreme Court agrees to hear ACA contraceptive mandate opt-out challenge
The U.S. Supreme Court is once again taking up a challenge to the Affordable Care Act – this time to determine whether a controversial exception under the law’s contraceptive mandate violates religious freedoms. The Nov. 6 decision to hear the debate comes just a year after justices ruled in Burwell v. Hobby Lobby Stores, in which the high court ruled that for-profit firms owned by religiously devout owners could not be forced to provide birth control coverage to their employees under the ACA.
This time, plaintiffs in seven cases argue that the birth control mandate’s accommodation process imposes substantial burdens on the exercise of religion in violation of the Religious Freedom Restoration Act. The accommodation clause refers to an exception for organizations that oppose coverage for contraceptives but are not exempted entities such as churches.
To get out of the ACA requirement to cover contraception as a preventive care service, companies must send their written objections to the federal government. Insurers and the government will then provide employees with coverage for birth control without the employer’s assistance.
The plaintiffs, including several religious groups and nonprofits, counter that the process serves as a “trigger” that enables contraceptive use and makes the groups complicit. The government argues the exception does impose a burden on the groups and that courts should not disregard the interest of employees who may not share employers’ religious beliefs.
The Supreme Court’s review will settle a split among circuit courts over the issue. The 8th U.S. Circuit Court of Appeals in September became the first circuit court to rule that the government’s religious freedom accommodation is not enough and that forcing organizations to offer contraceptive coverage – even indirectly – violates their religious rights. The court issued two decisions on Sept. 17 striking down the contraception mandate’s exception. The 8th Circuit decisions are at odds with rulings by the 2nd and 5th Circuits. Other judges have ruled that the accommodation relieves, rather than burdens, plaintiffs’ religious rights.
The high court has consolidated the seven cases for its evaluation. A hearing on the challenges is expected by late March.
On Twitter @legal_med
The U.S. Supreme Court is once again taking up a challenge to the Affordable Care Act – this time to determine whether a controversial exception under the law’s contraceptive mandate violates religious freedoms. The Nov. 6 decision to hear the debate comes just a year after justices ruled in Burwell v. Hobby Lobby Stores, in which the high court ruled that for-profit firms owned by religiously devout owners could not be forced to provide birth control coverage to their employees under the ACA.
This time, plaintiffs in seven cases argue that the birth control mandate’s accommodation process imposes substantial burdens on the exercise of religion in violation of the Religious Freedom Restoration Act. The accommodation clause refers to an exception for organizations that oppose coverage for contraceptives but are not exempted entities such as churches.
To get out of the ACA requirement to cover contraception as a preventive care service, companies must send their written objections to the federal government. Insurers and the government will then provide employees with coverage for birth control without the employer’s assistance.
The plaintiffs, including several religious groups and nonprofits, counter that the process serves as a “trigger” that enables contraceptive use and makes the groups complicit. The government argues the exception does impose a burden on the groups and that courts should not disregard the interest of employees who may not share employers’ religious beliefs.
The Supreme Court’s review will settle a split among circuit courts over the issue. The 8th U.S. Circuit Court of Appeals in September became the first circuit court to rule that the government’s religious freedom accommodation is not enough and that forcing organizations to offer contraceptive coverage – even indirectly – violates their religious rights. The court issued two decisions on Sept. 17 striking down the contraception mandate’s exception. The 8th Circuit decisions are at odds with rulings by the 2nd and 5th Circuits. Other judges have ruled that the accommodation relieves, rather than burdens, plaintiffs’ religious rights.
The high court has consolidated the seven cases for its evaluation. A hearing on the challenges is expected by late March.
On Twitter @legal_med
The U.S. Supreme Court is once again taking up a challenge to the Affordable Care Act – this time to determine whether a controversial exception under the law’s contraceptive mandate violates religious freedoms. The Nov. 6 decision to hear the debate comes just a year after justices ruled in Burwell v. Hobby Lobby Stores, in which the high court ruled that for-profit firms owned by religiously devout owners could not be forced to provide birth control coverage to their employees under the ACA.
This time, plaintiffs in seven cases argue that the birth control mandate’s accommodation process imposes substantial burdens on the exercise of religion in violation of the Religious Freedom Restoration Act. The accommodation clause refers to an exception for organizations that oppose coverage for contraceptives but are not exempted entities such as churches.
To get out of the ACA requirement to cover contraception as a preventive care service, companies must send their written objections to the federal government. Insurers and the government will then provide employees with coverage for birth control without the employer’s assistance.
The plaintiffs, including several religious groups and nonprofits, counter that the process serves as a “trigger” that enables contraceptive use and makes the groups complicit. The government argues the exception does impose a burden on the groups and that courts should not disregard the interest of employees who may not share employers’ religious beliefs.
The Supreme Court’s review will settle a split among circuit courts over the issue. The 8th U.S. Circuit Court of Appeals in September became the first circuit court to rule that the government’s religious freedom accommodation is not enough and that forcing organizations to offer contraceptive coverage – even indirectly – violates their religious rights. The court issued two decisions on Sept. 17 striking down the contraception mandate’s exception. The 8th Circuit decisions are at odds with rulings by the 2nd and 5th Circuits. Other judges have ruled that the accommodation relieves, rather than burdens, plaintiffs’ religious rights.
The high court has consolidated the seven cases for its evaluation. A hearing on the challenges is expected by late March.
On Twitter @legal_med
Small businesses snub Obamacare’s SHOP exchange
After nearly 2 years in operation and millions of dollars spent in development, the small business health insurance exchange created by the Affordable Care Act is struggling to catch on.
Nationally, about 85,000 people, from 11,000 small businesses, have coverage through the online marketplace known as the Small Business Health Options Program, or SHOP, according to the latest federal data released in May. Those totals do not include employers that began coverage in 2014 and have not yet renewed their coverage through HealthCare.gov for 2015.
That’s less than 1% of people with coverage in the U.S. small group insurance market that in 2013 had about 16.7 million people enrolled in health plans, reported Mark Farrah Associates, a market data firm.
The Congressional Budget Office in January estimated 1 million people would enroll for coverage through SHOP in 2015. No one expected the SHOP exchange to have a large enrollment, but industry officials say its early response has been substantially smaller than expected.
“When you look at the cost and look at the take up rate, it certainly raises questions” about whether SHOP has been worthwhile, said Alissa Fox, senior vice president of the Blue Cross Blue Shield Association. “We never thought the business equation made sense.”
Employers with fewer than 50 full-time workers are eligible to buy coverage on SHOP. The federal government even offers businesses an incentive, a tax credit worth up to half of an employer’s share of their workers’ premiums. Among the conditions: The firm must employ fewer than 25 workers and their average salary cannot exceed $50,000. The credit is hardly used in high-cost areas of the country where salaries are higher.
Similar to the health insurance marketplace for individuals, the federal government operates the SHOP exchange in 34 states, and 16 other states plus the District of Columbia run their own small business exchanges. The state exchanges also capture a small share of the small business market, based on more current figures compiled by Kaiser Health News. As of early October, five state-run SHOP exchanges – Idaho, Kentucky, Maryland, Minnesota, and Washington – had sold coverage to fewer than 200 employers. New York and California have the highest enrollments, and together those two states account for about 6,500 employers and nearly 50,000 people.
The Obama administration hoped SHOP would make it easier and cheaper for small employers to offer coverage to employees and for their workers to have a choice of plans.
Unlike the federal- and state-run health insurance exchanges for individuals that limit sign-up to a certain period during the year, the SHOP exchanges allow companies to enroll at any time.
But several factors account for the paltry enrollment in SHOP, say insurance brokers, insurers, and state officials. Brokers say SHOP has fewer health plans and more expensive coverage policies than can be purchased outside the exchange. Several states only have one insurer on their SHOP exchange, including Alabama, Tennessee, North Carolina and Nebraska, according to consulting firm Leavitt Partners.
Many small employers have stuck with plans they purchased outside SHOP because the Obama administration gave them the option to remain with their existing policies until 2017. That enabled employers to stay in plans that don’t meet all the new requirements of the health law, including so-called “essential health benefits.” These additional benefits can drive up the cost of policies, making it harder for the SHOP plans to compete.
Another factor that slowed enrollment in SHOP has been software problems in several states that made it hard for employers and employees to sign up. In addition, the SHOP exchange run by the federal government launched in October 2013 was only available if employers contacted an agent or broker. Its full website was not running until fall 2014.
“With all that stacked up against it, it does not surprise me that the numbers are so low,” said Kevin Lucia, a research professor at Georgetown University Health Policy Institute, who studied the rollout.
Kevin Counihan, the Obama administration’s top insurance exchange official, acknowledges SHOP will only be a “niche product” and most policies will still be sold outside the marketplace. Still, he expects as more employers and insurance brokers learn about SHOP, that its enrollment will grow. Asked in an interview about low enrollment, he said: “It doesn’t really bother me … something like this takes time.”
Mr. Counihan said the key will be to get more brokers interested in selling the SHOP plans.
But many brokers say they don’t see the value of SHOP since it typically offers fewer options than outside the exchanges. “There really is no reason to go to SHOP unless you qualify for the tax credits,” said Ken Stevenson, a Tallahassee, Fla., insurance agent. Four Florida insurers sell on SHOP, fewer than half available in the state. Florida Blue, the state’s largest insurer, said less than 1% of its small group policies are sold on the SHOP.
Other brokers say enrollment on SHOP is more confusing than working directly with carriers. “It’s difficult to get through the website, and it’s a lot easier for employers to pick up the phone and call a broker than spend 4 hours on the SHOP site,” said Alan Schulman, a Bethesda, Md., insurance agent.
The SHOP was set to expand to open for businesses with up to 100 employees in 2016, but Congress and President Obama rescinded that requirement in November.
One company to get the tax credit is Paloma Clothing, a women’s clothing store in Portland, Ore. Co-owner Mike Roach said he signed up for SHOP plan last year on the recommendation of his insurance agent. The credit saved his company about $7,000. That savings, he said, made it affordable for Paloma to keep its share of its employees’ monthly insurance premiums at 85%.
“The tax credit saved us from the terrific, morale-crushing option of decreasing our health insurance coverage for our employees,” he said. Eight of the store’s 15 employees signed up for the SHOP policy sold by Moda Health. Most pay about $45 a month for their share of the premium.
Mr. Roach said he is thankful for the health law. “Wow, finally someone did something to help small businesses deal with the rising cost of providing employees health insurance,” he said. “For so many years … no one did anything but feel sorry for you.”
After nearly 2 years in operation and millions of dollars spent in development, the small business health insurance exchange created by the Affordable Care Act is struggling to catch on.
Nationally, about 85,000 people, from 11,000 small businesses, have coverage through the online marketplace known as the Small Business Health Options Program, or SHOP, according to the latest federal data released in May. Those totals do not include employers that began coverage in 2014 and have not yet renewed their coverage through HealthCare.gov for 2015.
That’s less than 1% of people with coverage in the U.S. small group insurance market that in 2013 had about 16.7 million people enrolled in health plans, reported Mark Farrah Associates, a market data firm.
The Congressional Budget Office in January estimated 1 million people would enroll for coverage through SHOP in 2015. No one expected the SHOP exchange to have a large enrollment, but industry officials say its early response has been substantially smaller than expected.
“When you look at the cost and look at the take up rate, it certainly raises questions” about whether SHOP has been worthwhile, said Alissa Fox, senior vice president of the Blue Cross Blue Shield Association. “We never thought the business equation made sense.”
Employers with fewer than 50 full-time workers are eligible to buy coverage on SHOP. The federal government even offers businesses an incentive, a tax credit worth up to half of an employer’s share of their workers’ premiums. Among the conditions: The firm must employ fewer than 25 workers and their average salary cannot exceed $50,000. The credit is hardly used in high-cost areas of the country where salaries are higher.
Similar to the health insurance marketplace for individuals, the federal government operates the SHOP exchange in 34 states, and 16 other states plus the District of Columbia run their own small business exchanges. The state exchanges also capture a small share of the small business market, based on more current figures compiled by Kaiser Health News. As of early October, five state-run SHOP exchanges – Idaho, Kentucky, Maryland, Minnesota, and Washington – had sold coverage to fewer than 200 employers. New York and California have the highest enrollments, and together those two states account for about 6,500 employers and nearly 50,000 people.
The Obama administration hoped SHOP would make it easier and cheaper for small employers to offer coverage to employees and for their workers to have a choice of plans.
Unlike the federal- and state-run health insurance exchanges for individuals that limit sign-up to a certain period during the year, the SHOP exchanges allow companies to enroll at any time.
But several factors account for the paltry enrollment in SHOP, say insurance brokers, insurers, and state officials. Brokers say SHOP has fewer health plans and more expensive coverage policies than can be purchased outside the exchange. Several states only have one insurer on their SHOP exchange, including Alabama, Tennessee, North Carolina and Nebraska, according to consulting firm Leavitt Partners.
Many small employers have stuck with plans they purchased outside SHOP because the Obama administration gave them the option to remain with their existing policies until 2017. That enabled employers to stay in plans that don’t meet all the new requirements of the health law, including so-called “essential health benefits.” These additional benefits can drive up the cost of policies, making it harder for the SHOP plans to compete.
Another factor that slowed enrollment in SHOP has been software problems in several states that made it hard for employers and employees to sign up. In addition, the SHOP exchange run by the federal government launched in October 2013 was only available if employers contacted an agent or broker. Its full website was not running until fall 2014.
“With all that stacked up against it, it does not surprise me that the numbers are so low,” said Kevin Lucia, a research professor at Georgetown University Health Policy Institute, who studied the rollout.
Kevin Counihan, the Obama administration’s top insurance exchange official, acknowledges SHOP will only be a “niche product” and most policies will still be sold outside the marketplace. Still, he expects as more employers and insurance brokers learn about SHOP, that its enrollment will grow. Asked in an interview about low enrollment, he said: “It doesn’t really bother me … something like this takes time.”
Mr. Counihan said the key will be to get more brokers interested in selling the SHOP plans.
But many brokers say they don’t see the value of SHOP since it typically offers fewer options than outside the exchanges. “There really is no reason to go to SHOP unless you qualify for the tax credits,” said Ken Stevenson, a Tallahassee, Fla., insurance agent. Four Florida insurers sell on SHOP, fewer than half available in the state. Florida Blue, the state’s largest insurer, said less than 1% of its small group policies are sold on the SHOP.
Other brokers say enrollment on SHOP is more confusing than working directly with carriers. “It’s difficult to get through the website, and it’s a lot easier for employers to pick up the phone and call a broker than spend 4 hours on the SHOP site,” said Alan Schulman, a Bethesda, Md., insurance agent.
The SHOP was set to expand to open for businesses with up to 100 employees in 2016, but Congress and President Obama rescinded that requirement in November.
One company to get the tax credit is Paloma Clothing, a women’s clothing store in Portland, Ore. Co-owner Mike Roach said he signed up for SHOP plan last year on the recommendation of his insurance agent. The credit saved his company about $7,000. That savings, he said, made it affordable for Paloma to keep its share of its employees’ monthly insurance premiums at 85%.
“The tax credit saved us from the terrific, morale-crushing option of decreasing our health insurance coverage for our employees,” he said. Eight of the store’s 15 employees signed up for the SHOP policy sold by Moda Health. Most pay about $45 a month for their share of the premium.
Mr. Roach said he is thankful for the health law. “Wow, finally someone did something to help small businesses deal with the rising cost of providing employees health insurance,” he said. “For so many years … no one did anything but feel sorry for you.”
After nearly 2 years in operation and millions of dollars spent in development, the small business health insurance exchange created by the Affordable Care Act is struggling to catch on.
Nationally, about 85,000 people, from 11,000 small businesses, have coverage through the online marketplace known as the Small Business Health Options Program, or SHOP, according to the latest federal data released in May. Those totals do not include employers that began coverage in 2014 and have not yet renewed their coverage through HealthCare.gov for 2015.
That’s less than 1% of people with coverage in the U.S. small group insurance market that in 2013 had about 16.7 million people enrolled in health plans, reported Mark Farrah Associates, a market data firm.
The Congressional Budget Office in January estimated 1 million people would enroll for coverage through SHOP in 2015. No one expected the SHOP exchange to have a large enrollment, but industry officials say its early response has been substantially smaller than expected.
“When you look at the cost and look at the take up rate, it certainly raises questions” about whether SHOP has been worthwhile, said Alissa Fox, senior vice president of the Blue Cross Blue Shield Association. “We never thought the business equation made sense.”
Employers with fewer than 50 full-time workers are eligible to buy coverage on SHOP. The federal government even offers businesses an incentive, a tax credit worth up to half of an employer’s share of their workers’ premiums. Among the conditions: The firm must employ fewer than 25 workers and their average salary cannot exceed $50,000. The credit is hardly used in high-cost areas of the country where salaries are higher.
Similar to the health insurance marketplace for individuals, the federal government operates the SHOP exchange in 34 states, and 16 other states plus the District of Columbia run their own small business exchanges. The state exchanges also capture a small share of the small business market, based on more current figures compiled by Kaiser Health News. As of early October, five state-run SHOP exchanges – Idaho, Kentucky, Maryland, Minnesota, and Washington – had sold coverage to fewer than 200 employers. New York and California have the highest enrollments, and together those two states account for about 6,500 employers and nearly 50,000 people.
The Obama administration hoped SHOP would make it easier and cheaper for small employers to offer coverage to employees and for their workers to have a choice of plans.
Unlike the federal- and state-run health insurance exchanges for individuals that limit sign-up to a certain period during the year, the SHOP exchanges allow companies to enroll at any time.
But several factors account for the paltry enrollment in SHOP, say insurance brokers, insurers, and state officials. Brokers say SHOP has fewer health plans and more expensive coverage policies than can be purchased outside the exchange. Several states only have one insurer on their SHOP exchange, including Alabama, Tennessee, North Carolina and Nebraska, according to consulting firm Leavitt Partners.
Many small employers have stuck with plans they purchased outside SHOP because the Obama administration gave them the option to remain with their existing policies until 2017. That enabled employers to stay in plans that don’t meet all the new requirements of the health law, including so-called “essential health benefits.” These additional benefits can drive up the cost of policies, making it harder for the SHOP plans to compete.
Another factor that slowed enrollment in SHOP has been software problems in several states that made it hard for employers and employees to sign up. In addition, the SHOP exchange run by the federal government launched in October 2013 was only available if employers contacted an agent or broker. Its full website was not running until fall 2014.
“With all that stacked up against it, it does not surprise me that the numbers are so low,” said Kevin Lucia, a research professor at Georgetown University Health Policy Institute, who studied the rollout.
Kevin Counihan, the Obama administration’s top insurance exchange official, acknowledges SHOP will only be a “niche product” and most policies will still be sold outside the marketplace. Still, he expects as more employers and insurance brokers learn about SHOP, that its enrollment will grow. Asked in an interview about low enrollment, he said: “It doesn’t really bother me … something like this takes time.”
Mr. Counihan said the key will be to get more brokers interested in selling the SHOP plans.
But many brokers say they don’t see the value of SHOP since it typically offers fewer options than outside the exchanges. “There really is no reason to go to SHOP unless you qualify for the tax credits,” said Ken Stevenson, a Tallahassee, Fla., insurance agent. Four Florida insurers sell on SHOP, fewer than half available in the state. Florida Blue, the state’s largest insurer, said less than 1% of its small group policies are sold on the SHOP.
Other brokers say enrollment on SHOP is more confusing than working directly with carriers. “It’s difficult to get through the website, and it’s a lot easier for employers to pick up the phone and call a broker than spend 4 hours on the SHOP site,” said Alan Schulman, a Bethesda, Md., insurance agent.
The SHOP was set to expand to open for businesses with up to 100 employees in 2016, but Congress and President Obama rescinded that requirement in November.
One company to get the tax credit is Paloma Clothing, a women’s clothing store in Portland, Ore. Co-owner Mike Roach said he signed up for SHOP plan last year on the recommendation of his insurance agent. The credit saved his company about $7,000. That savings, he said, made it affordable for Paloma to keep its share of its employees’ monthly insurance premiums at 85%.
“The tax credit saved us from the terrific, morale-crushing option of decreasing our health insurance coverage for our employees,” he said. Eight of the store’s 15 employees signed up for the SHOP policy sold by Moda Health. Most pay about $45 a month for their share of the premium.
Mr. Roach said he is thankful for the health law. “Wow, finally someone did something to help small businesses deal with the rising cost of providing employees health insurance,” he said. “For so many years … no one did anything but feel sorry for you.”
AMA expands med schools in education consortium
The American Medical Association has added 20 schools to its Accelerating Change in Medical Education Consortium in an effort to better prepare students for the rapid change in medical practice.
“With medicine and health care delivery in the United States changing in such new and exciting ways, we’ve asked for and are starting to receive a medical education system that keeps pace with this rate of change,” Dr. James Madara, AMA chief operating officer, said during a Nov. 4 press teleconference. “This means trying new content, giving students information they need to know but in the past haven’t been taught, [and] trying new methods,” such as better understanding whether certain content is better shared through lecture or via simulation or electronic channels.
The program launched in 2013 with 11 schools. The new schools added were culled from proposals submitted by 108 of 170 eligible academic institutions.
“We sought proposals that would significantly redesign medical education and these experts reviewed entries with that goal in mind,” said Dr. Susan Skochelak, AMA group vice president for medical education. “The advisory panel evaluated each school’s proposal based on how the project would align with or enhance the 11 founding schools’ work and the projects’ uniqueness and feasibility for implementation at other medical schools.”
Winning programs cover concepts such as care coordination in accountable care organizations, advanced simulation and telemedicine technologies, and addressing the needs of underserved and diverse communities.
The new schools entering the consortium include A. T. Still University School of Osteopathic Medicine, Mesa, Ariz.; Case Western Reserve University, Cleveland; Eastern Virgina Medical School, Norfolk; Emory University, Atlanta; Florida International University, Miami; Harvard Medical School, Boston; Morehouse School of Medicine, Atlanta; Ohio University Heritage College of Osteopathic Medicine, Cleveland campus; Robert Wood Johnson Medical School, New Brunswick, N.J.; City College of New York Sophie Davis School of Biomedical Education, New York; Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia; University of Chicago; University of Connecticut, Farmington; University of Nebraska, Omaha; University of North Carolina at Chapel Hill; University of North Dakota, Grand Forks; University of Texas, Austin; University of Texas Rio Grande Valley School of Medicine, South Texas; University of Utah, Salt Lake City; and University of Washington, Seattle.
“By tripling the number of schools participating in this effort, we know that we will be able to more quickly disseminate the consortium schools’ innovative curriculum models to create the seismic shift that our medical education system needs so that our future physicians can better care for their patients,” Dr. Madara said.
The American Medical Association has added 20 schools to its Accelerating Change in Medical Education Consortium in an effort to better prepare students for the rapid change in medical practice.
“With medicine and health care delivery in the United States changing in such new and exciting ways, we’ve asked for and are starting to receive a medical education system that keeps pace with this rate of change,” Dr. James Madara, AMA chief operating officer, said during a Nov. 4 press teleconference. “This means trying new content, giving students information they need to know but in the past haven’t been taught, [and] trying new methods,” such as better understanding whether certain content is better shared through lecture or via simulation or electronic channels.
The program launched in 2013 with 11 schools. The new schools added were culled from proposals submitted by 108 of 170 eligible academic institutions.
“We sought proposals that would significantly redesign medical education and these experts reviewed entries with that goal in mind,” said Dr. Susan Skochelak, AMA group vice president for medical education. “The advisory panel evaluated each school’s proposal based on how the project would align with or enhance the 11 founding schools’ work and the projects’ uniqueness and feasibility for implementation at other medical schools.”
Winning programs cover concepts such as care coordination in accountable care organizations, advanced simulation and telemedicine technologies, and addressing the needs of underserved and diverse communities.
The new schools entering the consortium include A. T. Still University School of Osteopathic Medicine, Mesa, Ariz.; Case Western Reserve University, Cleveland; Eastern Virgina Medical School, Norfolk; Emory University, Atlanta; Florida International University, Miami; Harvard Medical School, Boston; Morehouse School of Medicine, Atlanta; Ohio University Heritage College of Osteopathic Medicine, Cleveland campus; Robert Wood Johnson Medical School, New Brunswick, N.J.; City College of New York Sophie Davis School of Biomedical Education, New York; Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia; University of Chicago; University of Connecticut, Farmington; University of Nebraska, Omaha; University of North Carolina at Chapel Hill; University of North Dakota, Grand Forks; University of Texas, Austin; University of Texas Rio Grande Valley School of Medicine, South Texas; University of Utah, Salt Lake City; and University of Washington, Seattle.
“By tripling the number of schools participating in this effort, we know that we will be able to more quickly disseminate the consortium schools’ innovative curriculum models to create the seismic shift that our medical education system needs so that our future physicians can better care for their patients,” Dr. Madara said.
The American Medical Association has added 20 schools to its Accelerating Change in Medical Education Consortium in an effort to better prepare students for the rapid change in medical practice.
“With medicine and health care delivery in the United States changing in such new and exciting ways, we’ve asked for and are starting to receive a medical education system that keeps pace with this rate of change,” Dr. James Madara, AMA chief operating officer, said during a Nov. 4 press teleconference. “This means trying new content, giving students information they need to know but in the past haven’t been taught, [and] trying new methods,” such as better understanding whether certain content is better shared through lecture or via simulation or electronic channels.
The program launched in 2013 with 11 schools. The new schools added were culled from proposals submitted by 108 of 170 eligible academic institutions.
“We sought proposals that would significantly redesign medical education and these experts reviewed entries with that goal in mind,” said Dr. Susan Skochelak, AMA group vice president for medical education. “The advisory panel evaluated each school’s proposal based on how the project would align with or enhance the 11 founding schools’ work and the projects’ uniqueness and feasibility for implementation at other medical schools.”
Winning programs cover concepts such as care coordination in accountable care organizations, advanced simulation and telemedicine technologies, and addressing the needs of underserved and diverse communities.
The new schools entering the consortium include A. T. Still University School of Osteopathic Medicine, Mesa, Ariz.; Case Western Reserve University, Cleveland; Eastern Virgina Medical School, Norfolk; Emory University, Atlanta; Florida International University, Miami; Harvard Medical School, Boston; Morehouse School of Medicine, Atlanta; Ohio University Heritage College of Osteopathic Medicine, Cleveland campus; Robert Wood Johnson Medical School, New Brunswick, N.J.; City College of New York Sophie Davis School of Biomedical Education, New York; Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia; University of Chicago; University of Connecticut, Farmington; University of Nebraska, Omaha; University of North Carolina at Chapel Hill; University of North Dakota, Grand Forks; University of Texas, Austin; University of Texas Rio Grande Valley School of Medicine, South Texas; University of Utah, Salt Lake City; and University of Washington, Seattle.
“By tripling the number of schools participating in this effort, we know that we will be able to more quickly disseminate the consortium schools’ innovative curriculum models to create the seismic shift that our medical education system needs so that our future physicians can better care for their patients,” Dr. Madara said.
Higher medical spending led to fewer malpractice claims
Greater than average spending was associated with reduced risk of incurring a malpractice claim across all physician specialties in a study of almost 25,000 doctors published Nov. 4 in the BMJ. The finding is consistent with widespread beliefs that higher resource use – sometimes defined as defensive medicine – limits the risk of litigation.
Dr. Anupam B. Jena of Harvard Medical School, Boston, and colleagues compared data from the Florida Agency for Health Care Administration on all acute care hospital discharges from 2000 to 2009 with data from the Florida Office of Insurance Regulation on all closed malpractice claims against Florida physicians during the same period. The data included 24,637 physicians (pediatricians, family physicians, general surgeons, obstetrician-gynecologists, and some subspecialists), more than 18 million hospital admissions, and 4,342 malpractice claims (BMJ 2015;351:h5516. doi: 10.1136/bmj.h5516). They looked at total hospital charges associated with patients treated by a given physician in a given year, averaged across all patients treated by that physician in that year, and adjusted for patient personal and clinical characteristics.
Across all specialties, higher average spending per year was associated with a lower probability of an alleged malpractice incident in the subsequent year. For internists, mean risk-adjusted spending per physician ranged from $19,725 for each hospital admission in the bottom fifth of physician years to $39,379 in the top fifth. The probability for an alleged malpractice claim ranged from 1.5% in the bottom spending fifth to 0.3% in the top spending fifth. Similarly, for ob.gyns., the probability of experiencing an alleged malpractice incident ranged from 1.9% in the bottom fifth of spending to 0.4% in the top fifth. Ob.gyns. on the low end of resource utilization spent a risk-adjusted mean of $8,653, while ob.gyns. on the high end spent $18,162.
Dr. Jena and colleagues also studied more than 1.5 million deliveries performed by 1,625 obstetricians; 15% were cesarean deliveries. In total, 496 malpractice claims were filed against these obstetricians. Ob.gyns. with higher cesarean rates per year were less likely to face a malpractice claim. The probability of being sued ranged from 5.7% in the bottom fifth of cesarean delivery rates to 2.7% in the top fifth.
Authors note that if higher spending is motivated by concerns about malpractice, then the spending would be considered “defensively motivated. However, that spending may not be wasteful if it is associated with fewer errors and therefore lower malpractice claims. More study is needed to compare the costs of additional resource use and the value of reduced errors to learn whether such defensively motivated care is socially wasteful or reflects socially beneficial deterrence.”
The study was supported by the National Institutes of Health.
On Twitter @legal_med
It may be tempting for doctors to view the results of the study by Dr. Jena and colleagues as a means to justify additional tests and procedures to mitigate the risk of a malpractice claim. We would suggest that they should view the study results as a contribution to our understanding of the risk of such claims. We need to better understand defensive medicine, how to define it, how to measure it, and how its practice impacts patients and doctors.
Dr. Tara F. Bishop and Dr. Michael Pesko are with the Department of Health Care Policy and Research at Weill Cornell Medical College in New York. Their comments were taken from an editorial accompanying Dr. Jena’s study (BMJ 2015;351:h5786. doi: 10.1136/bmj.h5786).
It may be tempting for doctors to view the results of the study by Dr. Jena and colleagues as a means to justify additional tests and procedures to mitigate the risk of a malpractice claim. We would suggest that they should view the study results as a contribution to our understanding of the risk of such claims. We need to better understand defensive medicine, how to define it, how to measure it, and how its practice impacts patients and doctors.
Dr. Tara F. Bishop and Dr. Michael Pesko are with the Department of Health Care Policy and Research at Weill Cornell Medical College in New York. Their comments were taken from an editorial accompanying Dr. Jena’s study (BMJ 2015;351:h5786. doi: 10.1136/bmj.h5786).
It may be tempting for doctors to view the results of the study by Dr. Jena and colleagues as a means to justify additional tests and procedures to mitigate the risk of a malpractice claim. We would suggest that they should view the study results as a contribution to our understanding of the risk of such claims. We need to better understand defensive medicine, how to define it, how to measure it, and how its practice impacts patients and doctors.
Dr. Tara F. Bishop and Dr. Michael Pesko are with the Department of Health Care Policy and Research at Weill Cornell Medical College in New York. Their comments were taken from an editorial accompanying Dr. Jena’s study (BMJ 2015;351:h5786. doi: 10.1136/bmj.h5786).
Greater than average spending was associated with reduced risk of incurring a malpractice claim across all physician specialties in a study of almost 25,000 doctors published Nov. 4 in the BMJ. The finding is consistent with widespread beliefs that higher resource use – sometimes defined as defensive medicine – limits the risk of litigation.
Dr. Anupam B. Jena of Harvard Medical School, Boston, and colleagues compared data from the Florida Agency for Health Care Administration on all acute care hospital discharges from 2000 to 2009 with data from the Florida Office of Insurance Regulation on all closed malpractice claims against Florida physicians during the same period. The data included 24,637 physicians (pediatricians, family physicians, general surgeons, obstetrician-gynecologists, and some subspecialists), more than 18 million hospital admissions, and 4,342 malpractice claims (BMJ 2015;351:h5516. doi: 10.1136/bmj.h5516). They looked at total hospital charges associated with patients treated by a given physician in a given year, averaged across all patients treated by that physician in that year, and adjusted for patient personal and clinical characteristics.
Across all specialties, higher average spending per year was associated with a lower probability of an alleged malpractice incident in the subsequent year. For internists, mean risk-adjusted spending per physician ranged from $19,725 for each hospital admission in the bottom fifth of physician years to $39,379 in the top fifth. The probability for an alleged malpractice claim ranged from 1.5% in the bottom spending fifth to 0.3% in the top spending fifth. Similarly, for ob.gyns., the probability of experiencing an alleged malpractice incident ranged from 1.9% in the bottom fifth of spending to 0.4% in the top fifth. Ob.gyns. on the low end of resource utilization spent a risk-adjusted mean of $8,653, while ob.gyns. on the high end spent $18,162.
Dr. Jena and colleagues also studied more than 1.5 million deliveries performed by 1,625 obstetricians; 15% were cesarean deliveries. In total, 496 malpractice claims were filed against these obstetricians. Ob.gyns. with higher cesarean rates per year were less likely to face a malpractice claim. The probability of being sued ranged from 5.7% in the bottom fifth of cesarean delivery rates to 2.7% in the top fifth.
Authors note that if higher spending is motivated by concerns about malpractice, then the spending would be considered “defensively motivated. However, that spending may not be wasteful if it is associated with fewer errors and therefore lower malpractice claims. More study is needed to compare the costs of additional resource use and the value of reduced errors to learn whether such defensively motivated care is socially wasteful or reflects socially beneficial deterrence.”
The study was supported by the National Institutes of Health.
On Twitter @legal_med
Greater than average spending was associated with reduced risk of incurring a malpractice claim across all physician specialties in a study of almost 25,000 doctors published Nov. 4 in the BMJ. The finding is consistent with widespread beliefs that higher resource use – sometimes defined as defensive medicine – limits the risk of litigation.
Dr. Anupam B. Jena of Harvard Medical School, Boston, and colleagues compared data from the Florida Agency for Health Care Administration on all acute care hospital discharges from 2000 to 2009 with data from the Florida Office of Insurance Regulation on all closed malpractice claims against Florida physicians during the same period. The data included 24,637 physicians (pediatricians, family physicians, general surgeons, obstetrician-gynecologists, and some subspecialists), more than 18 million hospital admissions, and 4,342 malpractice claims (BMJ 2015;351:h5516. doi: 10.1136/bmj.h5516). They looked at total hospital charges associated with patients treated by a given physician in a given year, averaged across all patients treated by that physician in that year, and adjusted for patient personal and clinical characteristics.
Across all specialties, higher average spending per year was associated with a lower probability of an alleged malpractice incident in the subsequent year. For internists, mean risk-adjusted spending per physician ranged from $19,725 for each hospital admission in the bottom fifth of physician years to $39,379 in the top fifth. The probability for an alleged malpractice claim ranged from 1.5% in the bottom spending fifth to 0.3% in the top spending fifth. Similarly, for ob.gyns., the probability of experiencing an alleged malpractice incident ranged from 1.9% in the bottom fifth of spending to 0.4% in the top fifth. Ob.gyns. on the low end of resource utilization spent a risk-adjusted mean of $8,653, while ob.gyns. on the high end spent $18,162.
Dr. Jena and colleagues also studied more than 1.5 million deliveries performed by 1,625 obstetricians; 15% were cesarean deliveries. In total, 496 malpractice claims were filed against these obstetricians. Ob.gyns. with higher cesarean rates per year were less likely to face a malpractice claim. The probability of being sued ranged from 5.7% in the bottom fifth of cesarean delivery rates to 2.7% in the top fifth.
Authors note that if higher spending is motivated by concerns about malpractice, then the spending would be considered “defensively motivated. However, that spending may not be wasteful if it is associated with fewer errors and therefore lower malpractice claims. More study is needed to compare the costs of additional resource use and the value of reduced errors to learn whether such defensively motivated care is socially wasteful or reflects socially beneficial deterrence.”
The study was supported by the National Institutes of Health.
On Twitter @legal_med
Which Hospitalist Should Bill for Inpatient Stays with Multiple Providers?
During a facility stay, a patient could be attended to by more than one hospitalist. For example, perhaps one hospitalist is the admitting physician, but the patient has a three-day stay and may be seen by three different hospitalists. Are there any guidelines as to which physician should be billed on the facility claim? Thank you for any remarks, suggestions, or references.
—Anonymous
Dr. Hospitalist responds:
Most of us can definitely relate to the concerns you have about properly billing during the patient’s hospital stay. By facility claim, I’m assuming you mean the physician’s bill for services rendered to a hospitalized patient. After querying the Centers for Medicare and Medicaid (CMS) website and discussing the question with several of our coding and billing gurus, as far as I can tell, there are no specific guidelines pertaining to which physician in a multiphysician group should bill. CMS guidelines are clear that you should only bill for the services you provide. CMS is very specific about allowing only one physician of the same specialty billing per day (reference the CMS Manual, Chapter 12, 30.6.9-Payment for Inpatient Hospital Visits).
In our very large group, we bill daily for the individual inpatient services we provide. That way, when the bill goes out, the clinician author is responsible for its validity and can support the level of care as documented.
Billing and coding is such an arduous process, I can’t imagine attempting it without an electronic interface. Most hospitalist groups have some form of electronic billing software that has integrated checks and balances to catch the common mistakes. Improper billing done by anyone in the group can expose the entire group to an audit. With ICD-10 now upon us, this becomes ever more important.
Good luck!
Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to drhospit@wiley.com.
During a facility stay, a patient could be attended to by more than one hospitalist. For example, perhaps one hospitalist is the admitting physician, but the patient has a three-day stay and may be seen by three different hospitalists. Are there any guidelines as to which physician should be billed on the facility claim? Thank you for any remarks, suggestions, or references.
—Anonymous
Dr. Hospitalist responds:
Most of us can definitely relate to the concerns you have about properly billing during the patient’s hospital stay. By facility claim, I’m assuming you mean the physician’s bill for services rendered to a hospitalized patient. After querying the Centers for Medicare and Medicaid (CMS) website and discussing the question with several of our coding and billing gurus, as far as I can tell, there are no specific guidelines pertaining to which physician in a multiphysician group should bill. CMS guidelines are clear that you should only bill for the services you provide. CMS is very specific about allowing only one physician of the same specialty billing per day (reference the CMS Manual, Chapter 12, 30.6.9-Payment for Inpatient Hospital Visits).
In our very large group, we bill daily for the individual inpatient services we provide. That way, when the bill goes out, the clinician author is responsible for its validity and can support the level of care as documented.
Billing and coding is such an arduous process, I can’t imagine attempting it without an electronic interface. Most hospitalist groups have some form of electronic billing software that has integrated checks and balances to catch the common mistakes. Improper billing done by anyone in the group can expose the entire group to an audit. With ICD-10 now upon us, this becomes ever more important.
Good luck!
Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to drhospit@wiley.com.
During a facility stay, a patient could be attended to by more than one hospitalist. For example, perhaps one hospitalist is the admitting physician, but the patient has a three-day stay and may be seen by three different hospitalists. Are there any guidelines as to which physician should be billed on the facility claim? Thank you for any remarks, suggestions, or references.
—Anonymous
Dr. Hospitalist responds:
Most of us can definitely relate to the concerns you have about properly billing during the patient’s hospital stay. By facility claim, I’m assuming you mean the physician’s bill for services rendered to a hospitalized patient. After querying the Centers for Medicare and Medicaid (CMS) website and discussing the question with several of our coding and billing gurus, as far as I can tell, there are no specific guidelines pertaining to which physician in a multiphysician group should bill. CMS guidelines are clear that you should only bill for the services you provide. CMS is very specific about allowing only one physician of the same specialty billing per day (reference the CMS Manual, Chapter 12, 30.6.9-Payment for Inpatient Hospital Visits).
In our very large group, we bill daily for the individual inpatient services we provide. That way, when the bill goes out, the clinician author is responsible for its validity and can support the level of care as documented.
Billing and coding is such an arduous process, I can’t imagine attempting it without an electronic interface. Most hospitalist groups have some form of electronic billing software that has integrated checks and balances to catch the common mistakes. Improper billing done by anyone in the group can expose the entire group to an audit. With ICD-10 now upon us, this becomes ever more important.
Good luck!
Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to drhospit@wiley.com.
Eliminations Hospitalist Groups Should Consider
Editor’s note: Second in a continuing series of articles exploring ways hospitalist groups can cut back.
In last month’s column, I made the case that most hospitalist groups should think about doing away with a morning meeting to distribute overnight admissions and changing a daytime admitter shift into another rounder and having all of the day rounders share admissions. Here I’ll describe additional things in place at some hospitalist groups that should probably be eliminated.
Obscuring Attending Hospitalist Name
Some hospitalist groups admit patients to the “blue team” or “gold team” or use a similar system. I encountered one place that had a fuchsia team. Such designations typically take the place of the attending physician’s name and can be convenient when one hospitalist goes off service and is replaced by another; the team name stays the same. Even if the attending hospitalist makes up the entire team (i.e., no residents or students), some groups use the “team” name rather than the attending hospitalist name.
But when the patient’s chart, sign on the door, and other identifying materials all refer only to the team that is caring for the patient, the patients, their families, and most hospital staff don’t have an easy way to identify the responsible physician. Say a worried daughter steps into the hall to ask the nurse, “Which doctor is taking care of my dad?” The nurse might readily see that the blue team is responsible but may not know which hospitalist is working on the blue team today and might have to walk back to the nursing station to look over a sheet of paper (a “decoder ring”) to figure out the hospitalist’s name.
This scenario has all kinds of drawbacks. To the daughter, the name of the doctor in charge is a big deal. It doesn’t inspire confidence if the nurse can’t readily say who that is. And the busy nurse might forget to investigate and provide the name to the daughter in a timely way.
I think groups using a system like this should seriously consider replacing team names with the attending hospitalist name and updating that name in the medical record, whether that is an EHR, a paper chart, or some other form, every time that doctor rotates off service and is replaced by another. Hospital staff, patients, and families should always see the name of the attending physician and not an uninformative color or nondescript team name.
It will require work for someone, the hospitalist in many cases, to go into the EHR and write an order or send a message to ensure that the hospitalist name is kept current every time one doctor replaces another. But it’s worth the effort.
Day Hospitalists Should Round on Patients Admitted after Midnight
Although not exactly common, I’ve come across this scenario often enough that it’s worth mentioning.
Hospitalists, sometimes with a hint of indignity or even chest thumping, have told me they don’t visit or round on patients admitted after midnight by their night doctor. “You can’t bill for a second visit on the same calendar day,” they explain, firmly. “So if I can’t get paid to see the patient, then I won’t.”
This is just crazy.
For one thing, these same doctors are typically employed by the hospital and are being paid to provide whatever care patients need. I think they’ve just latched onto the “can’t bill another visit” as an excuse to get out of some work.
Don’t forget that many of these patients may wait over 30 hours from their admitting visit to the first follow-up visit; this delay is at the beginning of their hospital stay, when they might be most unstable. And it delays initiation of discharge planning and other important steps in patient care.
I don’t see any room for meaningful debate on this. The rounder who picks up a patient admitted the night before should always make a full rounding visit, even if the admission was after midnight.
But if the visit isn’t billable, you are freed from the typical billing-related documentation requirements. No need to document detail in the note that doesn’t meaningfully contribute to the care of the patient. For example, you might omit a chief complaint for this encounter.
Daytime Triage Doctor
Practices larger than about 20 full-time equivalents often have one daytime doctor hold a “triage” or “hot” pager, which others call to make a new referral. This triage doctor will hear about all referrals and keep track of and contact the hospitalist responsible for the next new patient. This can be a very busy job and often comes on top of a full clinical load for that doctor.
As I mentioned in my July 2015 and December 2010 articles, in many or most groups, a clerical person could take over this function, at least during business hours.
Vacation Time
In many or most cases, hospitalists that have specified vacation time are not getting a better deal than those that have no vacation time. What really matters is how many shifts you’re responsible for in a year. For the days you aren’t on shift, in most hospitalist groups it really doesn’t matter whether you label some of them as vacation days or CME days.
I discussed this issue in greater detail in my March 2007 article.
But if you’re in the 30% of hospitalist groups that have a vacation (or PTO) provision currently and it works well, then there certainly isn’t a compelling reason to change or do away with it.
Editor’s note: Second in a continuing series of articles exploring ways hospitalist groups can cut back.
In last month’s column, I made the case that most hospitalist groups should think about doing away with a morning meeting to distribute overnight admissions and changing a daytime admitter shift into another rounder and having all of the day rounders share admissions. Here I’ll describe additional things in place at some hospitalist groups that should probably be eliminated.
Obscuring Attending Hospitalist Name
Some hospitalist groups admit patients to the “blue team” or “gold team” or use a similar system. I encountered one place that had a fuchsia team. Such designations typically take the place of the attending physician’s name and can be convenient when one hospitalist goes off service and is replaced by another; the team name stays the same. Even if the attending hospitalist makes up the entire team (i.e., no residents or students), some groups use the “team” name rather than the attending hospitalist name.
But when the patient’s chart, sign on the door, and other identifying materials all refer only to the team that is caring for the patient, the patients, their families, and most hospital staff don’t have an easy way to identify the responsible physician. Say a worried daughter steps into the hall to ask the nurse, “Which doctor is taking care of my dad?” The nurse might readily see that the blue team is responsible but may not know which hospitalist is working on the blue team today and might have to walk back to the nursing station to look over a sheet of paper (a “decoder ring”) to figure out the hospitalist’s name.
This scenario has all kinds of drawbacks. To the daughter, the name of the doctor in charge is a big deal. It doesn’t inspire confidence if the nurse can’t readily say who that is. And the busy nurse might forget to investigate and provide the name to the daughter in a timely way.
I think groups using a system like this should seriously consider replacing team names with the attending hospitalist name and updating that name in the medical record, whether that is an EHR, a paper chart, or some other form, every time that doctor rotates off service and is replaced by another. Hospital staff, patients, and families should always see the name of the attending physician and not an uninformative color or nondescript team name.
It will require work for someone, the hospitalist in many cases, to go into the EHR and write an order or send a message to ensure that the hospitalist name is kept current every time one doctor replaces another. But it’s worth the effort.
Day Hospitalists Should Round on Patients Admitted after Midnight
Although not exactly common, I’ve come across this scenario often enough that it’s worth mentioning.
Hospitalists, sometimes with a hint of indignity or even chest thumping, have told me they don’t visit or round on patients admitted after midnight by their night doctor. “You can’t bill for a second visit on the same calendar day,” they explain, firmly. “So if I can’t get paid to see the patient, then I won’t.”
This is just crazy.
For one thing, these same doctors are typically employed by the hospital and are being paid to provide whatever care patients need. I think they’ve just latched onto the “can’t bill another visit” as an excuse to get out of some work.
Don’t forget that many of these patients may wait over 30 hours from their admitting visit to the first follow-up visit; this delay is at the beginning of their hospital stay, when they might be most unstable. And it delays initiation of discharge planning and other important steps in patient care.
I don’t see any room for meaningful debate on this. The rounder who picks up a patient admitted the night before should always make a full rounding visit, even if the admission was after midnight.
But if the visit isn’t billable, you are freed from the typical billing-related documentation requirements. No need to document detail in the note that doesn’t meaningfully contribute to the care of the patient. For example, you might omit a chief complaint for this encounter.
Daytime Triage Doctor
Practices larger than about 20 full-time equivalents often have one daytime doctor hold a “triage” or “hot” pager, which others call to make a new referral. This triage doctor will hear about all referrals and keep track of and contact the hospitalist responsible for the next new patient. This can be a very busy job and often comes on top of a full clinical load for that doctor.
As I mentioned in my July 2015 and December 2010 articles, in many or most groups, a clerical person could take over this function, at least during business hours.
Vacation Time
In many or most cases, hospitalists that have specified vacation time are not getting a better deal than those that have no vacation time. What really matters is how many shifts you’re responsible for in a year. For the days you aren’t on shift, in most hospitalist groups it really doesn’t matter whether you label some of them as vacation days or CME days.
I discussed this issue in greater detail in my March 2007 article.
But if you’re in the 30% of hospitalist groups that have a vacation (or PTO) provision currently and it works well, then there certainly isn’t a compelling reason to change or do away with it.
Editor’s note: Second in a continuing series of articles exploring ways hospitalist groups can cut back.
In last month’s column, I made the case that most hospitalist groups should think about doing away with a morning meeting to distribute overnight admissions and changing a daytime admitter shift into another rounder and having all of the day rounders share admissions. Here I’ll describe additional things in place at some hospitalist groups that should probably be eliminated.
Obscuring Attending Hospitalist Name
Some hospitalist groups admit patients to the “blue team” or “gold team” or use a similar system. I encountered one place that had a fuchsia team. Such designations typically take the place of the attending physician’s name and can be convenient when one hospitalist goes off service and is replaced by another; the team name stays the same. Even if the attending hospitalist makes up the entire team (i.e., no residents or students), some groups use the “team” name rather than the attending hospitalist name.
But when the patient’s chart, sign on the door, and other identifying materials all refer only to the team that is caring for the patient, the patients, their families, and most hospital staff don’t have an easy way to identify the responsible physician. Say a worried daughter steps into the hall to ask the nurse, “Which doctor is taking care of my dad?” The nurse might readily see that the blue team is responsible but may not know which hospitalist is working on the blue team today and might have to walk back to the nursing station to look over a sheet of paper (a “decoder ring”) to figure out the hospitalist’s name.
This scenario has all kinds of drawbacks. To the daughter, the name of the doctor in charge is a big deal. It doesn’t inspire confidence if the nurse can’t readily say who that is. And the busy nurse might forget to investigate and provide the name to the daughter in a timely way.
I think groups using a system like this should seriously consider replacing team names with the attending hospitalist name and updating that name in the medical record, whether that is an EHR, a paper chart, or some other form, every time that doctor rotates off service and is replaced by another. Hospital staff, patients, and families should always see the name of the attending physician and not an uninformative color or nondescript team name.
It will require work for someone, the hospitalist in many cases, to go into the EHR and write an order or send a message to ensure that the hospitalist name is kept current every time one doctor replaces another. But it’s worth the effort.
Day Hospitalists Should Round on Patients Admitted after Midnight
Although not exactly common, I’ve come across this scenario often enough that it’s worth mentioning.
Hospitalists, sometimes with a hint of indignity or even chest thumping, have told me they don’t visit or round on patients admitted after midnight by their night doctor. “You can’t bill for a second visit on the same calendar day,” they explain, firmly. “So if I can’t get paid to see the patient, then I won’t.”
This is just crazy.
For one thing, these same doctors are typically employed by the hospital and are being paid to provide whatever care patients need. I think they’ve just latched onto the “can’t bill another visit” as an excuse to get out of some work.
Don’t forget that many of these patients may wait over 30 hours from their admitting visit to the first follow-up visit; this delay is at the beginning of their hospital stay, when they might be most unstable. And it delays initiation of discharge planning and other important steps in patient care.
I don’t see any room for meaningful debate on this. The rounder who picks up a patient admitted the night before should always make a full rounding visit, even if the admission was after midnight.
But if the visit isn’t billable, you are freed from the typical billing-related documentation requirements. No need to document detail in the note that doesn’t meaningfully contribute to the care of the patient. For example, you might omit a chief complaint for this encounter.
Daytime Triage Doctor
Practices larger than about 20 full-time equivalents often have one daytime doctor hold a “triage” or “hot” pager, which others call to make a new referral. This triage doctor will hear about all referrals and keep track of and contact the hospitalist responsible for the next new patient. This can be a very busy job and often comes on top of a full clinical load for that doctor.
As I mentioned in my July 2015 and December 2010 articles, in many or most groups, a clerical person could take over this function, at least during business hours.
Vacation Time
In many or most cases, hospitalists that have specified vacation time are not getting a better deal than those that have no vacation time. What really matters is how many shifts you’re responsible for in a year. For the days you aren’t on shift, in most hospitalist groups it really doesn’t matter whether you label some of them as vacation days or CME days.
I discussed this issue in greater detail in my March 2007 article.
But if you’re in the 30% of hospitalist groups that have a vacation (or PTO) provision currently and it works well, then there certainly isn’t a compelling reason to change or do away with it.
CMS finalizes 2016 fee schedule with payment for advance care planning
Officials at the Centers for Medicare & Medicaid Services have issued the final 2016 fee schedule for physicians, making modifications to the Physician Quality Reporting System (PQRS) and loosening requirements for its controversial two-midnight rule.
The fee schedule – the first since repeal of the Sustainable Growth Rate (SGR) formula and enactment of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) – includes changes to payment policies, modifications to misvalued codes, and updates to quality performance metrics under the PQRS, the Medicare Shared Savings Program, and Physician Compare, among others.
As part of the final fee schedule rule, released Oct. 30, CMS is relaxing its two-midnight rule to allow doctors greater flexibility when determining whether hospital stays are subject to the regulation.
For hospital stays for which physicians expect the patient will need less than two midnights of hospital care, an inpatient admission may still be payable under Medicare Part A on a case-by-case basis based on the admitting physician’s judgment, according to the final rule. Additionally, the agency does not plan to send recovery auditors after doctors suspected of violating the two-midnight rule. Instead, CMS plans to use Beneficiary and Family Centered Care Quality Improvement Organizations to conduct initial medical reviews of claims for short-stay inpatient admissions. The claim reviews will focus on educating physicians and hospitals about the policy for inpatient admissions.
Only physicians with questionable practice patterns, such as high rates of claims denial after medical review, will be referred to auditors, according to CMS.
“These changes continue CMS’ long-standing emphasis on the importance of a physician’s medical judgment in meeting the needs of Medicare beneficiaries,” CMS officials stated in a fact sheet.
CMS also finalized two new advance care planning codes that will pay physicians for time spent discussing patient options for advance directives. The first code will cover an initial 30 minutes of the physicians’ time, and the second code will cover additional 30-minute blocks as necessary.
The AMA Current Procedural Terminology (CPT) Editorial Panel and the AMA Relative Value Update Committee (RUC) created the new CPT codes and recommended the associated payments for calendar year 2015, but CMS delayed the codes’ enactment until collecting public comment.
Modifications to quality programs include a new reporting option under the PQRS that will allow group practices to report quality measure data using a Qualified Clinical Data Registry. In 2016, there will be 281 measures in the PQRS measure set and 18 measures in the Group Practice Reporting Option (GPRO) Web Interface, according to the final rule.
The 2018 payment adjustment will be the last adjustment under the PQRS. Starting in 2019, adjustments to payment for quality reporting and other factors will be made under the Merit-Based Incentive Payment System (MIPS), as required by MACRA.
Changes to the Value-Based Payment Modifier program are also coming in 2016:
• CMS will apply the quality-tiering methodology to all groups and solo practitioners that meet the criteria to avoid the downward adjustment under the PQRS. Groups and solo practitioners would be subject to upward, neutral, or downward adjustments derived under the quality-tiering methodology.
• CMS will continue to set the maximum upward adjustment under the quality-tiering methodology for the CY 2018 value modifier at four times an adjustment factor for groups of physicians with 10 or more eligible professionals, and two times an adjustment factor for groups of physicians with between two and nine eligible professionals and physician solo practitioners.
• CMS will use calendar year 2016 as the performance period for the calendar 2018 value modifier and continue to apply the 2018 value modifier based on participation in the PQRS by groups and solo practitioners.
The fee schedule also includes modifications to the Medicare Shared Savings Program including a new measure on statin therapy for the prevention and treatment of cardiovascular disease in the “preventive health domain” of the Shared Savings Program quality measure set. The final rule also clarifies how PQRS-eligible professionals participating within an Accountable Care Organization can meet reporting requirements.
On Twitter @legal_med
Officials at the Centers for Medicare & Medicaid Services have issued the final 2016 fee schedule for physicians, making modifications to the Physician Quality Reporting System (PQRS) and loosening requirements for its controversial two-midnight rule.
The fee schedule – the first since repeal of the Sustainable Growth Rate (SGR) formula and enactment of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) – includes changes to payment policies, modifications to misvalued codes, and updates to quality performance metrics under the PQRS, the Medicare Shared Savings Program, and Physician Compare, among others.
As part of the final fee schedule rule, released Oct. 30, CMS is relaxing its two-midnight rule to allow doctors greater flexibility when determining whether hospital stays are subject to the regulation.
For hospital stays for which physicians expect the patient will need less than two midnights of hospital care, an inpatient admission may still be payable under Medicare Part A on a case-by-case basis based on the admitting physician’s judgment, according to the final rule. Additionally, the agency does not plan to send recovery auditors after doctors suspected of violating the two-midnight rule. Instead, CMS plans to use Beneficiary and Family Centered Care Quality Improvement Organizations to conduct initial medical reviews of claims for short-stay inpatient admissions. The claim reviews will focus on educating physicians and hospitals about the policy for inpatient admissions.
Only physicians with questionable practice patterns, such as high rates of claims denial after medical review, will be referred to auditors, according to CMS.
“These changes continue CMS’ long-standing emphasis on the importance of a physician’s medical judgment in meeting the needs of Medicare beneficiaries,” CMS officials stated in a fact sheet.
CMS also finalized two new advance care planning codes that will pay physicians for time spent discussing patient options for advance directives. The first code will cover an initial 30 minutes of the physicians’ time, and the second code will cover additional 30-minute blocks as necessary.
The AMA Current Procedural Terminology (CPT) Editorial Panel and the AMA Relative Value Update Committee (RUC) created the new CPT codes and recommended the associated payments for calendar year 2015, but CMS delayed the codes’ enactment until collecting public comment.
Modifications to quality programs include a new reporting option under the PQRS that will allow group practices to report quality measure data using a Qualified Clinical Data Registry. In 2016, there will be 281 measures in the PQRS measure set and 18 measures in the Group Practice Reporting Option (GPRO) Web Interface, according to the final rule.
The 2018 payment adjustment will be the last adjustment under the PQRS. Starting in 2019, adjustments to payment for quality reporting and other factors will be made under the Merit-Based Incentive Payment System (MIPS), as required by MACRA.
Changes to the Value-Based Payment Modifier program are also coming in 2016:
• CMS will apply the quality-tiering methodology to all groups and solo practitioners that meet the criteria to avoid the downward adjustment under the PQRS. Groups and solo practitioners would be subject to upward, neutral, or downward adjustments derived under the quality-tiering methodology.
• CMS will continue to set the maximum upward adjustment under the quality-tiering methodology for the CY 2018 value modifier at four times an adjustment factor for groups of physicians with 10 or more eligible professionals, and two times an adjustment factor for groups of physicians with between two and nine eligible professionals and physician solo practitioners.
• CMS will use calendar year 2016 as the performance period for the calendar 2018 value modifier and continue to apply the 2018 value modifier based on participation in the PQRS by groups and solo practitioners.
The fee schedule also includes modifications to the Medicare Shared Savings Program including a new measure on statin therapy for the prevention and treatment of cardiovascular disease in the “preventive health domain” of the Shared Savings Program quality measure set. The final rule also clarifies how PQRS-eligible professionals participating within an Accountable Care Organization can meet reporting requirements.
On Twitter @legal_med
Officials at the Centers for Medicare & Medicaid Services have issued the final 2016 fee schedule for physicians, making modifications to the Physician Quality Reporting System (PQRS) and loosening requirements for its controversial two-midnight rule.
The fee schedule – the first since repeal of the Sustainable Growth Rate (SGR) formula and enactment of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) – includes changes to payment policies, modifications to misvalued codes, and updates to quality performance metrics under the PQRS, the Medicare Shared Savings Program, and Physician Compare, among others.
As part of the final fee schedule rule, released Oct. 30, CMS is relaxing its two-midnight rule to allow doctors greater flexibility when determining whether hospital stays are subject to the regulation.
For hospital stays for which physicians expect the patient will need less than two midnights of hospital care, an inpatient admission may still be payable under Medicare Part A on a case-by-case basis based on the admitting physician’s judgment, according to the final rule. Additionally, the agency does not plan to send recovery auditors after doctors suspected of violating the two-midnight rule. Instead, CMS plans to use Beneficiary and Family Centered Care Quality Improvement Organizations to conduct initial medical reviews of claims for short-stay inpatient admissions. The claim reviews will focus on educating physicians and hospitals about the policy for inpatient admissions.
Only physicians with questionable practice patterns, such as high rates of claims denial after medical review, will be referred to auditors, according to CMS.
“These changes continue CMS’ long-standing emphasis on the importance of a physician’s medical judgment in meeting the needs of Medicare beneficiaries,” CMS officials stated in a fact sheet.
CMS also finalized two new advance care planning codes that will pay physicians for time spent discussing patient options for advance directives. The first code will cover an initial 30 minutes of the physicians’ time, and the second code will cover additional 30-minute blocks as necessary.
The AMA Current Procedural Terminology (CPT) Editorial Panel and the AMA Relative Value Update Committee (RUC) created the new CPT codes and recommended the associated payments for calendar year 2015, but CMS delayed the codes’ enactment until collecting public comment.
Modifications to quality programs include a new reporting option under the PQRS that will allow group practices to report quality measure data using a Qualified Clinical Data Registry. In 2016, there will be 281 measures in the PQRS measure set and 18 measures in the Group Practice Reporting Option (GPRO) Web Interface, according to the final rule.
The 2018 payment adjustment will be the last adjustment under the PQRS. Starting in 2019, adjustments to payment for quality reporting and other factors will be made under the Merit-Based Incentive Payment System (MIPS), as required by MACRA.
Changes to the Value-Based Payment Modifier program are also coming in 2016:
• CMS will apply the quality-tiering methodology to all groups and solo practitioners that meet the criteria to avoid the downward adjustment under the PQRS. Groups and solo practitioners would be subject to upward, neutral, or downward adjustments derived under the quality-tiering methodology.
• CMS will continue to set the maximum upward adjustment under the quality-tiering methodology for the CY 2018 value modifier at four times an adjustment factor for groups of physicians with 10 or more eligible professionals, and two times an adjustment factor for groups of physicians with between two and nine eligible professionals and physician solo practitioners.
• CMS will use calendar year 2016 as the performance period for the calendar 2018 value modifier and continue to apply the 2018 value modifier based on participation in the PQRS by groups and solo practitioners.
The fee schedule also includes modifications to the Medicare Shared Savings Program including a new measure on statin therapy for the prevention and treatment of cardiovascular disease in the “preventive health domain” of the Shared Savings Program quality measure set. The final rule also clarifies how PQRS-eligible professionals participating within an Accountable Care Organization can meet reporting requirements.
On Twitter @legal_med
