Health care reform: a status report

As Congress' August recess approaches, it is becoming clear that passage of a health care reform bill that expands coverage and restrains costs is not going to happen this summer, as many had expected. In both the House and the Senate, bills are stuck in committee, but Congressional leaders vow they'll be ready for a vote this fall.

In the House, the 1,000-page America's Affordable Health Choices Act (HR 3200) has been approved by the Ways and Means Committee and the Education and Labor Committee but has stalled with the Energy and Commerce Committee. The fiscally conservative Blue Dog Democrats have refused to pass the bill until cost concerns have been resolved. An analysis by the Congressional Budget Office recently concluded that the plan would cost $1 trillion and increase the federal budget deficit by $239 billion over the next decade. Lawmakers' latest idea of establishing an independent panel to make cuts to Medicare would only save about $2 billion, according to the CBO.

Key features of the House plan as it now stands include the following:

• a new government-run health insurance plan that would compete with private insurers,
• penalties for employers who do not provide health insurance for their employees (with a small business exemption) and for individuals who do not purchase it,
• subsidies for lower- and middle-class families to pay for health insurance premiums,
• a prohibition on denying coverage because of health status or pre-existing conditions,
• a health insurance exchange that would help individuals and small businesses comparison shop among private and public options,
• caps on annual out-of-pocket expenses,
• an expanded and improved Medicaid program,
• a prohibition on cost-sharing for preventive services,
• elimination of the Medicare Part D “donut hole,”
• Medicare reform, including repeal of the flawed sustainable growth rate (SGR) formula,
• a 5-percent increase in Medicare payments for designated services provided by primary care physicians,
• a 1-percent surtax on households earning more than $350,000,
• a 5.4-percent surtax on households earning more than $1,000,000.

In the Senate, the Affordable Health Choices Act, sponsored by Sen. Edward Kennedy, has been approved by the Health, Education, Labor and Pensions Committee. Its coverage provisions are similar to those in the House bill. Meanwhile, the Finance Committee, led by Sen. Max Baucus, is working on its own bill, with debate focused primarily on the funding of health care reform. The two versions will need to be combined into a single bill before going to the full Senate for a vote.

While there's progress in Washington, the public may be having some misgivings. The latest USA Today/Gallup poll found that more Americans disapprove (50 percent) than approve (44 percent) of the way the President is handling health care policy. New York Times columnist David Brooks speculated as to why: "People have a legitimate question: How is it we're going to cut my costs by creating a new trillion-dollar entitlement? ... How are we going to control costs without anybody sacrificing anything?"

Obama's prime-time news conference last Wednesday was intended to build support for health care reform, but syndicated columnist Mark Shields observed that the speech may have fallen short: "All I could think of was, Adlai Stevenson once said when he was introducing John Kennedy -- remember in classical times, whenever Cicero spoke, the people reacted and said, 'He spoke so well.' But when Demosthenes spoke, the people said, 'Let us march.' And after the Wednesday presentation, there was nobody saying, 'Let us march.'"

Posted at 01:36PM Jul 29, 2009 by Brandi White  |  Comments[1]

Feds define ‘meaningful use' of health IT

Physicians hoping to qualify for up to $44,000 in federal funds for implementing an EHR should take note of the meaningful-use criteria approved July 16 by the Office of the National Coordinator for Health Information Technology's Health IT Policy Committee. The group's recommendations will be incorporated into a final rule from the Centers for Medicare & Medicaid Services due Jan. 1, 2010. Although not yet final, the recently released criteria give physicians a better sense of what their EHR systems will need to be able to do come 2011.

The year-one meaningful-use criteria for physicians (hospitals have separate criteria) fall under five areas and include the following:

Improving quality, safety and efficiency and reducing health disparities

• Use computerized entry for all orders (medication, laboratory, procedure, diagnostic imaging, immunization, referral) although electronic interfaces to receiving entities are not required in 2011
• Implement drug-drug, drug-allergy and drug-formulary checks
• Maintain an up-to-date problem list of current and active diagnoses based on ICD-9 or SNOMED
• Generate and transmit permissible prescriptions electronically
• Maintain active medication list and medication allergy list
• Record demographics (preferred language, insurance type, gender, race and ethnicity)
• Record advance directives
• Record vital signs (height, weight, blood pressure, BMI) and smoking status
• Incorporate lab-test results into EHR as structured data
• Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities and outreach
• Report ambulatory quality measures to CMS
• Send reminders to patients per patient preference for preventive/follow-up care
• Implement on decision rule relevant to specialty or high clinical priority
• Document a progress note for each encounter
• Check insurance eligibility electronically from public and private payers, where possible
• Submit claims electronically to public and private payers

Engaging patients and families

• Provide patients with an electronic copy of or electronic access to their health information (including lab results, problem list, medication lists, allergies) upon request
• Provide access to patient-specific educational resources
• Provide clinical summaries for patients for each encounter

Improving care coordination

• Electronically exchange key clinical information (e.g., problem list, medication list, allergies, test results) among providers of care and patient-authorized entities
• Perform medication reconciliation at relevant encounters and each transition of care (i.e., moving patients from one setting or provider to another)

Population and public health reporting

• Submit electronic data to immunization registries where required and accepted
• Provide electronic syndrome surveillance data to public health agencies according to applicable law and practice

Ensuring privacy and security

• Comply with federal and state HIPAA rules
• Comply with fair data sharing practices set forth in the Nationwide Privacy and Security Framework

Proving compliance
To prove compliance with these criteria in year one of EHR implementation in order to receive the federal incentives, physicians will have to report on roughly 30 measures, such as percentage of diabetics with A1C under control, percentage of smokers offered smoking-cessation counseling, percentage of all medications entered into EHR as generic when generic options exist and percentage of claims submitted electronically to all payers.

To view all of the measures, see the "Meaningful Use Matrix." This document also lists the criteria for 2013 and 2015 (or year three and year five of EHR implementation).

A major concern for physicians is whether the 2011 measures as a whole will be achievable. Additionally, there is concern that physicians won’t understand the details of what’s required to demonstrate meaningful use and will implement an EHR but fail to qualify for the stimulus payments.

Posted at 09:42AM Jul 21, 2009 by Brandi White  |  Comments[3]

Could your practice's waiting area become obsolete?

Could a web-based “virtual queue management system” that allows patients to use their cell phones to hold their spot in line eventually replace waiting areas in physicians’ practices? Alex Bäcker, PhD (no relation of mine), the founder and CEO of abInventio, which makes QLess, believes it could. (Bäcker’s mission is actually far more ambitious: to wipe waiting lines off the face of the Earth.)

This type of system is different than those you might have encountered in some restaurants. There’s no electronic device to distribute and no need to stay on the premises. Patients could check into a line by sending a text message or making a phone call. When their turn in line has come up, they would simply receive a text message or phone call.

It’s probably too soon to begin thinking about remodeling your waiting area into another exam room – the idea has yet to take hold in health care. But it’s worth thinking about. Imagine how a system like this one could help some practices compete with retail health clinics that enable patients to shop while they wait to be seen. Imagine being able to offer patients an alternative to rubbing elbows with sick patients in your potentially crowded waiting room – one that would allow them to use their waiting time more productively. Having recently experienced a lengthy wait at a doctor’s office (not my family physician’s), I must say that eliminating the “waiting problem,” as Bäcker describes it, would give new meaning to patient-centered care and service.

Posted at 03:39PM Jul 10, 2009 by Leigh Ann Backer  |  Comments[0]

"You're likely to hear a lot more about this idea"

Proponents of the patient-centered medical home gained a high-profile advocate this week – New York Times health columnist Jane Brody. Highlighting care provided by family physician Gloria Trujillo, MD, at Duke University Family Medicine Center, Brody's Monday column, "A Personal, Coordinated Approach to Care," highlights the medical home's potential to heal the U.S. health care system, both for patients and physicians: "As President Obama and Congress try to create a national system that provides better care for more people at lower cost, you are likely to hear a lot more about this idea."

Posted at 11:05AM Jun 25, 2009 by Lynn Hofeldt  |  Comments[0]

Solving the cost conundrum: Lessons from Grand Junction

An article in the June 1st New Yorker by physician and medical journalist Atul Gawande, MD, should be required reading for physicians concerned about the economics of medical practice. And what family physician isn’t? “The Cost Conundrum” presents the results of an investigation that began with the Dartmouth Atlas and led Gawande to one of the highest-cost health care communities in the U.S. – McAllen, Texas – and to one of the lowest – Grand Junction, Colo. – in search of an explanation for the three-fold difference in Medicare spending between these two cities. In exploring several hypotheses, Gawande contrasts the medical cultures in these communities and arrives at a conclusion sure to make many a physician squirm: The source of the difference in health care spending is “overuse of medicine” by hospitals and physicians alike. “Physicians in places like McAllen behave differently from others. The $2.4-trillion question is why. Unless we figure it out, health reform will fail,” Gawande writes.

The article captured the interest of President Obama, who cited the article in a meeting with two dozen Democratic senators earlier this week and said in effect, "This is what we've got to fix," according to one senator quoted in the New York Times.

Gawande suggests that cities like McAllen would be better served by “accountable-care organizations” like Grand Junction’s, “in which doctors collaborate to increase prevention and the quality of care, while discouraging overtreatment, undertreatment, and sheer profiteering.”

Roger Shenkel, MD, a physician leader in Grand Junction, Colo., was a member of the FPM Board of Editors for more than 10 years. During this time he wrote or co-authored a number of articles that reveal some of the health care strategies and tactics that underlie his community’s success. Dr. Shenkel also introduced us to his Grand Junction colleague Phil Mohler, MD, who wrote or co-authored several FPM articles that share the same themes of cost-effectiveness, quality and collaboration between physicians, medical groups, administrators and payers. We think you’ll find the articles as timely and useful now as when we first published them:

• New Drugs: How to Decide Which Ones to Prescribe
• Improving Chronic Illness Care: Lessons Learned in a Private Practice
• 1-800-Chronic Disease Management
• Weighing the Risks and Benefits of Clinical Interventions
• What Every Physician Should Know About Generic Drugs
• Creating a Successful After-Hours Clinic
• Building Rapport With Consultants: A Matter of Economics
• IPA Formation in Rural America: Nothing Like the City Slickers Do
• Medicaid Miracle in Mesa County
• Rural Managed Care: A 20-Year Road to Success

Posted at 04:09PM Jun 12, 2009 by Leigh Ann Backer  |  Comments[0]

Barbara Starfield on Family Medicine and the PCMH

The work of Barbara Starfield, MD, MPH, has been enormously effective in establishing the value of primary care in general and family medicine in particular. One testimony to this is the AAFP’s list of 100 articles demonstrating the value of family medicine; she wrote or coauthored 18 of the 100 articles.

Given her strong support of primary care, it’s reasonable to want to know her thoughts on the Patient-Centered Medical Home (PCMH), a concept that seems likely to shape the future of the specialty. In an opinion piece written for the July/August issue of Family Practice Management, she sounds somewhat dubious of the direction the PCMH is taking: “Proposals for the PCMH are not very patient-centered. They are justified on the basis of evidence regarding the benefits of primary care, but the criteria for assessment of PCMHs, such as those promulgated by the National Committee for Quality Assurance, concern organizational features such as electronic health records, computerized guidelines and amorphous 'teams,' none of which have been demonstrated to be pursuant to good primary care.”

To read more, see the prepublication version of her essay.

Posted at 11:59AM Jun 01, 2009 by Bob Edsall  |  Comments[1]

If you build it, will they come?

One of the challenges to widespread implementation of the patient-centered medical home (PCMH) is to ensure that patients understand the concept and actively seek this model of care for themselves and their families. To help explain the PCMH to patients, the Patient-Centered Primary Care Collaborative (PCPCC) has released a free, web-based multimedia program. The PCPCC is a coalition of more than 400 organizations, including the AAFP and TransforMed, that are working together to develop and advance the PCMH. Representatives of PCPCC member organizations collaborated with Emmi Solutions to develop the four-minute program, which is available to practices, employers, advocacy groups and others interested in sharing it with consumers. Check it out on the PCPCC web site. If you're new to the PCMH concept, or even if you believe you've heard it all before, watching the video might be as helpful to you as it is to your patients.

Posted at 12:15PM May 22, 2009 by Leigh Ann Backer  |  Comments[0]

FPM: The Twitter Edition

With 17 million people on Twitter, we figured that there must be some family physicians, so naturally we wanted FPM to be there, too. Now there's a Twitter version of FPM – FPMJournal. If you follow our feed there, you can keep up with what's in the regular issues, our e-mail newsletter and the FPM blogs. And if you're just curious to know how we can squeeze an FPM article into 140 characters, check out our new face on Twitter. And if you're an FPM reader who happens to have a Twitter life as well, drop us an @ message to let us know what you think.

That makes four ways you can get FPM: online at our web site, in our digital edition, in print (by subscription), and now through Twitter.

Posted at 02:03PM May 20, 2009 by Bob Edsall  |  Comments[0]

Health care isn't recession-proof, says survey

The troubled economy may be causing more patients to worry about health care costs and, in some cases, forgo needed care, according to the results of a recent AAFP survey of 505 family physicians.

Nearly 90 percent of the family physician respondents said more of their patients have expressed concerns recently about their ability to pay for their health care needs; 73 percent have seen an increase in uninsured patients in their practices; 58 percent have seen an increase in appointment cancellations; and 54 percent reported a drop in patient volume since January 2008.

Additionally, 73 percent of respondents said they have seen evidence of patients cutting prescription doses to save money, and 60 percent have seen more health problems caused by patients forgoing needed preventive care.

How are FPs responding? Two-thirds said they were taking steps such as discounting their fees, increasing charity care, providing free screenings and moving patients to generic prescriptions. Forty-four percent said they are having to cut, or consider cutting, services or staff.

Posted at 01:29PM May 19, 2009 by Brandi White  |  Comments[0]

AAFP members and FPM subscribers: Submit your CME quizzes online

AAFP members and paid subscribers to Family Practice Management can now take an interactive, online version of the CME quiz and submit their responses electronically for CME credit. Previously, subscribers were required to submit the paper quiz card found in their printed copy of the journal.

Readers can earn more than 18 CME credits per year via Family Practice Management's CME Quiz.

The online version of American Family Physician's CME Quiz is also now available to subscribers.

Posted at 11:20AM May 19, 2009 by Brandi White  |  Comments[0]

What we now know about the patient-centered medical home

Three years and some $8 million ago, the AAFP boldly launched TransforMed, whose primary mission was to carry out a national demonstration project (NDP) to test a model of the patient-centered medical home (PCMH) in 36 practices throughout the United States.

Yesterday, the first researchers' report, based primarily on the project's qualitative data, was published in the Annals of Family Medicine. According to the researchers, "Even though analysis of the NDP is not yet complete, we feel compelled to share early lessons ...  We have already learned enough from the NDP to identify some potentially dangerous red flags fluttering over the [PCMH] demonstrations just getting underway."

Here's what the researchers found:

1. Becoming a PCMH (as defined by the TransforMed model, now on version 2.3) requires "epic," "relentless," "practice-wide" change that will likely produce "change fatigue" among the doctors and staff.

2. The technology needed for the PCMH is not "plug and play"; instead, its implementation is "more difficult and time consuming than originally envisioned," in part because systems aren't interoperable.

3. The amount of change required to become a PCMH "takes more time than the two years allocated to the NDP."

4. Transforming to a PCMH requires tremendous costs, in terms of dollars, time and effort, and "currently available funds and reimbursements are likely to be inadequate."

As daunting as that sounds, it might actually be worth the trouble if there is evidence that the PCMH model as currently defined (with its dozens of components) makes a difference for patients. But does it? That's the million-dollar question. The research team has collected data on the patient experience and clinical outcomes for the 36 practices in the NDP, but those reports aren't slated for publication until early 2010. Judging from the tone of the researchers' first article, it's hard to believe that the coming data will be positive.

The researchers note that for practices to become PCMHs under the current model, they need more time, more money and better technology. That could be. Or is there something amiss with the PCMH model itself? Read one view on that question from the well-known researcher Barbara Starfield, MD, MPH, in an editorial for Family Practice Management.

Posted at 02:04PM May 12, 2009 by Brandi White  |  Comments[1]

H1N1 articles now available online

To help you respond to the current H1N1 flu outbreak and other infectious disease challenges your practice will face in the future, the AAFP journals are publishing three new articles online, prior to print publication.

The following articles are available free and in full text online; they will be printed in future issues of the journals:

American Family Physician

• Basic Rules of Influenza: How to Combat the H1N1 Influenza (Swine Flu) Virus
• Telephone Triage of Patients With Influenza

By Jonathan L. Temte, MD, PhD, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; AAFP Liaison to the Advisory Committee on Immunization Practices

Family Practice Management

• Preparing Your Office for an Infectious Disease Epidemic

By Charles W. Mackett III, MD, associate professor and executive vice chairman of the Department of Family Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pa.

Posted at 02:33PM May 08, 2009 by Brandi White  |  Comments[0]

Obama: "We're not producing enough primary care physicians"

A New York Times story this week suggests that the Obama administration understands that a shortage of primary care physicians could undermine health care reform. Family physicians, particularly those in rural and urban areas, know this all too well. Others need look no farther than Massachusetts, where a plan for near-universal coverage has been unfolding over the last three years, to see that without significantly greater numbers of primary care doctors, the expansion of coverage that Obama has championed is likely to drive costs higher.

A study last year predicted a shortage of 35,000 to 44,000 adult care generalists by 2025, and that was before expanded coverage was the realistic possibility it seems today.

Federal officials are considering several proposals for dealing with the growing shortage, according to the New York Times article: increasing enrollment in medical schools and residency training programs, encouraging greater use of nurse practitioners and physician assistants, expanding the National Health Service Corps, and increasing Medicare payments to primary care physicians. If the latter has to be done in a budget-neutral way, at the expense of payment to specialists, look for dysfunction in the house of medicine, or worse. “A civil war among physicians seems inevitable,” blogger KevinMD predicts.

Posted at 10:03AM Apr 30, 2009 by Leigh Ann Backer  |  Comments[1]

Waving a white flag for Red Flags compliance

As if CLIA, OSHA and HIPAA enforcement aren't burdensome enough, the deadline to implement the new federal Identity Theft Red Flags Rule is looming. Your practice may be required to have anti-identity theft measures in place by Aug. 1.

The Federal Trade Commission, which will enforce the new regulations, surprised many in medicine earlier this year by determining that the rules also apply to health care organizations, not just financial institutions and lenders as originally thought.

Whether your practice is subject to the Red Flags Rule depends on whether your practice’s specific billing and collection practices qualify you a "creditor."

“Under the rule, a physician or practice is a creditor if they extend 'credit,' which means they regularly defer payment for goods or services and have covered accounts. A covered account is (1) an account primarily for personal, family, or household purposes, that involves or is designed to permit multiple payments or transactions, or (2) any other account for which there is a reasonably foreseeable risk to customers, or the safety and soundness of the financial institution or creditor, from identity theft.”

In other words, a practice (or physician) is considered a creditor if it does not regularly demand payment in full for services at the time of service.

Practices subject to the Red Flags Rule must develop, implement and administer an Identity Theft Prevention Program that includes four basic elements:

1. Reasonable policies and procedures to identify suspicious patterns or practices, or specific activities that indicate the possibility of identity theft in your practice.
2. Procedures for detecting the red flags you’ve identified.
3. An action plan to follow when a red flag is detected.
4. A plan for re-evaluating your program at least annually to reflect new risks.

The Red Flags Rule requires that the program be incorporated into the daily operations of the practice, that it be clear who is responsible for implementing and administering it and that staff be trained accordingly. The AAFP has developed a PowerPoint presentation to help members and their staff learn about and implement the Red Flags Rule. This is one of several resources available at the AAFP's Identity Theft Red Flags Rule Web page.

Posted at 02:49PM Apr 23, 2009 by Lynn Hofeldt  |  Comments[0]

Medical-legal partnerships: The biopsychosocial-legal model

Think how useful it would be to have an attorney down the hall ready to help low-income patients with living wills, health care powers of attorney, Medicare problems, disability claims, public housing applications and all the other legal sequelae of disease. Doctors in a growing number of hospitals, residency programs and clinics across the country are finding out just how useful it can be. Medical-legal partnerships are bringing attorneys into the clinical setting to help vulnerable patients cope with the legal dimensions of disease.

The National Center for Medical-Legal Partnerships (NCMLP) lists 81 medical-legal partnerships that are currently serving twice that number of health care facilities across the country. While early medical-legal partnerships focused more on serving children and their families, partnerships are now being set up in family medicine contexts. One of those, the Tucson Family Advocacy Program at the University of Arizona in Tucson, was profiled last year in an Arizona Daily Star article. Other family-medicine-oriented medical-legal partnerships listed by the NCMLP include one in California, one in Iowa and one in Montana. If you are interested in exploring the development of a medical-legal partnership in your area, the NCMLP offers assistance.

Posted at 09:26AM Apr 20, 2009 by Bob Edsall  |  Comments[0]