Category Archives: health reform

ACA: Helping or Hurting Solo Practice?

It won’t surprise many to learn that the age of the solo practitioner has, for the most part, come to an end. Over the past several years, small and solo practices have closed, been sold to hospitals, or merged with larger groups. The reasons are fairly obvious. Declining payments, rising malpractice costs, increasing regulatory burdens, costly new health information technology requirements, and crushing medical school debt have made it difficult for physicians to operate the small practices that once were commonplace around the country.

Now add the Affordable Care Act (ACA) to the mix. At a July 19 hearing of the House Small Business Subcommittee on Investigations, Oversight and Regulations, lawmakers questioned whether the health reform law would help or hurt physicians looking to keep their practices small and independent. The answers from the expert panel were mixed.

Gone are the days of Marcus Welby. Courtesy Wikimedia Commons/Public Domain License

The emergence of accountable care organizations (ACOs) will drive more hospitals to buy up small physician practices, Mark Smith, president of the physician recruiting firm Merritt Hawkins, predicted. The health reform law heavily promotes the formation of ACOs, which call for physicians and hospitals to work more closely and to share in bundled payments for episodes of care. Mr. Smith said small practices aren’t well-positioned to enter the ACO world if they aren’t integrated with a hospital because the ACO model calls on practices to assume financial risk.

But Joseph M. Yasso, Jr., DO, a family physician in Independence, Mo., who sold his practice to a hospital group 20 years ago, said the ACA’s promotion of patient-centered medical homes could be a lifeline for small practices. Physicians are adapting to the new environment by becoming medical homes and participating in government pilots where they can share in the savings they generate by providing more efficient care, he said.

One thing everyone on the panel did agree on was the need to fix the Sustainable Growth Rate (SGR) formula used in setting physician payments under Medicare. No surprises there either.

— Mary Ellen Schneider

Leave a comment

Filed under Health IT, Health Policy, health reform, IMNG, Litigation, Physician Reimbursement, Practice Trends, Primary care

Louisiana’s Medicaid Nightmare

Physicians in Louisiana may find themselves holding the short end of the stick very soon, as the state struggles to figure out how to make up a sudden $859 million shortfall in Medicaid funding.

And it comes at a time when the state’s Republican governor, Bobby Jindal, has said that he will not take any additional federal money to expand the Medicaid program in 2014, as offered under the Affordable Care Act. He also said he would not accept federal funds to set up health insurance exchanges under the law.

Bobby Jindal. Courtesy Wikimedia Commons/dsb nola/Creative Commons Attribution 2.0 Generic License

If any hospital or physician wanted to know what it would feel like to go without that federal money, they now have their chance. The $859 million hole is the result of a reduction in the federal matching rate that Congress approved as part of the transportation bill that was signed by President Obama on July 6.

The provision affects only Louisiana. After Hurricanes Katrina and Rita, the state received hundreds of millions in aid. But there was no adjustment at that time in the federal Medicaid matching rate. So Louisiana’s Medicaid program was the recipient of millions of dollars more than what it was due. (For more on this byzantine situation, see the New Orleans Times-Picayune’s story here.)

Congress fixed that error in the transportation and student loan bill by dropping the state’s current match rate. But Gov. Jindal, in creating and finalizing his fiscal 2013 budget, was, ironically, depending on that federal money.

On July 13, his administration announced cuts to make up the shortfall. The decrease in the federal matching rate meant that the state had to come up with $287 million in cuts on its own; the rest of the $859 million will come from reductions in pay from the federal government.

According to the state Dept. of Health and Human Services, $518 million will come out of the pockets of physicians and hospitals.  The state already had announced an across-the-board almost 4% cut in Medicaid provider rates for fiscal 2013.

Under the latest cuts, the Louisiana State University system is taking the biggest hit: $329 million, or a quarter of its budget, according to news reports. LSU is one of the biggest charity care providers in the state. Interestingly, DHHS commented in its press release that it “does not anticipate this reduction of [disproportionate share hospitals] and Medicaid payments to affect Medicaid recipients’ access to hospital care.”

Among the other programs absorbing blows: the Greater New Orleans Community Health Connection (GNOCHC), a pilot that expanded health coverage to uninsured adults in the wake of Hurricane Katrina. Another program that provided family planning services to low-income women will have its qualifying income limit reduced from 200% to 133% of the Federal Poverty Level.

The state is also tightening its review of eligibility for all Medicaid recipients.

After the cuts were announced, the Louisiana Hospital Association said in a statement that, the total elimination of DSH payments to rural hospitals “will be critical and will lead to reductions in services and possible hospital closures.” That in turn will leave ” gaps in healthcare delivery for patients in rural areas, as well as economic losses to those communities,” said LHA.

With hospitals across the state possibly delivering less care, it seems likely that physicians could expect to see more pressure on their practices.

Alicia Ault

1 Comment

Filed under Health Policy, health reform, IMNG, Practice Trends, Primary care

Physicians Grapple With Efficiency, ‘Do No Harm’

Two new books and a news article triangulate some interesting thoughts on improving efficiency in medicine while causing less harm to patients – and what that really means.

IMNG Medical Media reporter Alicia Ault’s feature story on “Can More Be Done with Less?” describes a recent conference on “Avoiding Avoidable Care” that brought medical experts together to strategize on how to avoid unnecessary tests and treatment, which can harm patients.

Dr. Vikas Saini, an organizer of the conference, told her that patients often demand tests or procedures because they seek certainty and want to know that the physician cares. But test results often lead to false knowledge, said Dr. Saini of the Lown Cardiovascular Research Foundation, which cosponsored the meeting. The key for physicians, he said, is to convincingly explain to patients why the test or procedure is or is not a good idea, and to practice evidence-based medicine.

To do that, though, requires an ability to interpret medical research and help patients understand it. That’s where Dr. Marya D. Zilberberg’s new book comes in. Between the Lines: Finding the Truth in Medical Literature is a breezy 170-page primer that spends most of the first half of the book cheerleading for scientific uncertainty. She also reviews the hierarchies of quality in research and touches on heterogeneity, biases, and a few general pitfalls in interpreting studies.

The second half of Between the Lines goes a little deeper in explaining study design, validity, statistical analyses, and more, though never so deeply that a nonstatistician’s eyes will glaze over. Dr. Zilberberg, a consultant, teacher, and blogger at Healthcare, Inc., explains these dry subjects in an eminently readable fashion.

I found it a valuable refresher (especially Part Two) even though I’ve been covering medical news for over two decades, and I imagine it would be a great introduction for the uninitiated. Dr. Kenneth W. Lin, a family physician who teaches a course in evidence-based medicine at Georgetown University, posted an online review that called Between the Lines “a rare book that bridges the gulf between medical publications and the real world of practicing clinicians.” Paul D. Simmons, Ph.D., who teaches family medicine residents in Louisville, Ky., said in an online review that he hopes incorporating the book will decrease the number of residents who finish his rotation thinking that evidence-based medicine is impractical, takes too much time, requires a Ph.D. in biostatistics, and doesn’t apply to their careers.

A separate book approaches these themes in ways that question medicine’s sometimes heavy-handed emphasis on “evidence” and “efficiency.” In God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine, Dr. Victoria Sweet eloquently recounts her 20 years of working at a chronic-care hospital for the ill and indigent (considered the “last almshouse in America”) as it morphs into a “modern healthcare treatment facility.”

Dr. Sweet’s scathing depictions of “efficiency” at the expense of time with patients bolster her call for “slow medicine” and the (missing) research to compare the two.

Disclosure: I’ve known Dr. Sweet for many years and even consider her a friend. I esteemed the book on its merits, and so did neurologist and author Dr. Oliver Sacks, whose book-jacket blurb called it, “A most important book, which raises fundamental questions about the nature of medicine in our time. It should be required reading.”

Dr. Abigail Zuger’s review in The New York Times began, “It is probably pointless to suggest that all the individuals presently shaping our health care future spend a quiet weekend with ‘God’s Hotel,’ Dr. Victoria Sweet’s transcendent testament to health care past. Who interrupts cowboys in the midst of a stampede? But if you’re one of the millions of doctors and patients out there choking on their dust, this is the book for you. Its compulsively readable chapters go down like restorative sips of cool water, and its hard-core subversion cheers like a shot of gin.”

The synchronicity of these three works is a sign of the times. As physicians are asked to do more with less, these writings help us understand what you’ve got to work with.

–Sherry Boschert (@sherryboschert on Twitter)

5 Comments

Filed under Cardiovascular Medicine, Family Medicine, Health Policy, health reform, Hospital and Critical Care Medicine, IMNG, Internal Medicine, Uncategorized

Annual Meeting Focuses on Echocardiography and Its Future

©Ekko/Wikimedia Commons

Multimodality imaging is among the highlights of this year’s American Society of Echocardiography meeting, which starts on June 30 at the National Harbor, Maryland.

The society is pushing forward the concept, looking at different diseases and integrating different kinds of imaging such as echo plus nuclear, Cardiac CT, or Cardiac MR, in order to get the best diagnoses, said Dr. Melissa Wood, co-director of Massachusetts General Hospital Heart Center Women’s Heart Health Program, Boston, and the chair of ASE Public Relations Committee.

“This isn’t just about echo, it’s also about all the other imaging techniques that are out there and how we can work together and deliver the highest quality of care,” said Dr. Wood in an interview. “It’s also about what’s superfluous, and what we don’t need to do.”

On the policy front, Accountable Care Organizations will be in the forefront during the meeting. Dr. Wood said that the speakers will address how “ACOs affect those of us who read echos and do them, and how they affect practices.”

Echocardiography will also leave this planet for a bit during a symposium. ASE president Dr. James Thomas has been in the past actively involved in doing research with the space station and helping pick the right echo machine to go up there, said Dr. Wood. “There’s substantial interest in microgravity and the heart, and how heart changes its function in space. It’s something that’s very unique, and there are lessons that can be learned from that, and that experience will be somehow useful in our clinical practices, whether it’s specific type of research techniques or specific types of information that are gained in that environment.”

Echocardiography is the second most commonly ordered test after EKG, according to Dr. Wood, and with the aging population, the use of the test is likely to increase.

“I see echo take off more because of this concern about heart failure being an epidemic. Echo as a way to diagnose heart failure before it becomes profound,” she said. And given the appropriate use criteria, “we’re tying to moderate the reasons echos are ordered, so they’ll continue to be fairly reimbursed by third parties and CMS (Centers for Medicare and Medicaid Services),” said Dr. Wood.

You can find the meeting’s program here. And be sure to check our coverage on ecardiologynews.com.

By Naseem S. Miller (@NaseemSMiller)

Leave a comment

Filed under Cardiovascular Medicine, Health Policy, health reform, Practice Trends

IOM Unveils Hot Reads in Time for Summer

In case you’re looking for something more meaningful to read this summer than Fifty Shades of Grey or Abraham Lincoln: Vampire Hunter, The Institute of Medicine has released some dandy reports suitable for reading or for hiding those trashy beach novels.

First up, in May, IOM released Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation. The report focuses on five critical goals for preventing obesity:

  • integrating physical activity into people’s daily lives,
  • making healthy food and beverage options available everywhere,
  • transforming marketing and messages about nutrition and activity,
  • making schools a gateway to healthy weights, and
  • galvanizing employers and health care professionals to support healthy lifestyles.

The committee outlined specific strategies include: requiring at least 60 minutes per day of physical education and activity in schools, industry-wide guidelines on which foods and beverages can be marketed to children and how, expansion of workplace wellness programs, taking full advantage of physicians’ roles to advocate for obesity prevention with patients and in the community, and increasing the availability of lower-calorie, healthier children’s meals in restaurants.

Also in May, IOM published Ethical and Scientific Issues in Studying the Safety of Approved Drugs. In response to the passage of the Food and Drug Administration Act in 2007, the FDA asked the IOM to evaluate scientific and ethical aspects of safety studies for approved drugs. The IOM concluded that the FDA’s current approach to drug oversight in the postmarket setting is not systematic enough and does not ensure that benefits and risks of drugs are assessed consistently over the drug’s life cycle.  “Adopting a regulatory framework that is standardized across all drugs, yet flexible enough to adapt to regulatory decisions of differing complexity, could help make the agency’s decision-making process more predictable, transparent, and proactive. These changes could allow the FDA to better anticipate postapproval research needs and improve drug safety for all Americans.”

Finally, for the ambitious reader, the IOM had just released the discussion paper A CEO Checklist for High-Value Health Care. Despite risking costs, healthcare remains suboptimal in many areas. “To aid and accelerate the system-wide transformation necessary, we have assembled what we are calling “A CEO Checklist for High-Value Care” (the Checklist). The Checklist’s 10 items reflect the strategies that, in our experiences and those of others, have proven effective and essential to improving quality and reducing costs. They describe the foundational, infrastructure, care delivery, and feedback components of a system oriented around value, and represent basic opportunities—indeed obligations—for hospital and health care delivery system CEOs and Boards to improve the value of health care in their institutions.”

The 10 items include:

  • Governance priority—visible and determined leadership by CEO and Board
  • Culture of continuous improvement—commitment to ongoing, real-time learning
  •  IT best practices—automated, reliable information to and from the point of care
  • Evidence protocols—effective, efficient, and consistent care
  • Resource utilization—optimized use of personnel, physical space, and other resources
  • Integrated care—right care, right setting, right providers, right teamwork
  • Shared decision making—patient–clinician collaboration on care plans
  • Targeted services—tailored community and clinic interventions for resource-intensive patients
  • Embedded safeguards—supports and prompts to reduce injury and infection
  • Internal transparency—visible progress in performance, outcomes, and costs

Kerri Wachter (On Twitter @knwachter)

Leave a comment

Filed under Drug And Device Safety, Health Policy, health reform, IMNG, Primary care

PMA Process Taking Longer and Longer

In the medical device arena, pre-market approval (PMA) submissions to the FDA keep taking longer and longer to process, according to Bob Rhatigan, senior vice president of facial aesthetics for Allergan Inc. 

“A decade ago we used to see a PMA approval time of 9-12 months,” Mr. Rhatigan told attendees of the Summit in Aesthetic Medicine 2012. “In the middle of the last decade, that increased to 16 months, and as recently as 2010, that time frame is over 2 years. It’s something that we are anxiously watching. We don’t see any signs of that abating.” 

The implications are gloomy for clinicians engaged in research of medical devices who wish to continue working in the United States. The current regulatory environment, Mr. Rhatigan said, “is working to push clinical research and studies outside of the U.S. market. It is not inconceivable, looking forward, to think about the bulk if not all of clinical research moving offshore as a result of companies like Allergan needing to get products approved more quickly. We are a bit pessimistic right now but [are] attempting to influence [legislators], as we want to make sure innovation in this industry continues to be ripe in the U.S. market.” 

— Doug Brunk (on Twitter@dougbrunk)

1 Comment

Filed under Dermatology, Drug And Device Safety, health reform, IMNG, Practice Trends

Health Officials to Docs: Help Save ACA

Health officials are encouraging doctors who support the health law to help save it. By telling patients about how the Affordable Care Act will benefit them and the entire system, physicians can help garner support for the ACA, said Kathleen Sebelius, secretary of Health and Human Services.

“The notion that [you] are going to share factual information and have people share that information with friends and neighbors and patients on websites, in blogs, and church groups, and at [parent/teacher organization meetings], that’s really what makes a huge impact,” Ms. Sebelius said while addressing primary care and specialist physicians at the annual conference of Doctors for America. She added that doctors should not only spread the news, but become a part of the process as well.

“Your comments, certainly, about what is happening in rulemaking is helpful … but more than that is participating in some of the new models of care,” Ms. Sebelius said.

Many physicians are skeptical about the ACA according to some surveys. However, Doctors for America is among those who support of the law. It remains to be seen whether there’s enough agreement among doctors to make a difference.  What do you think? Tell us in the comments section.

—Frances Correa (@FMCReporting on Twitter)

1 Comment

Filed under health reform, IMNG, Practice Trends, Uncategorized

A Hospitalist’s Call to Action

Dr. Patrick Conway is the Chief Medical Officer at the Centers for Medicare and Medicaid Services, but he also happens to be a practicing pediatric hospitalist. So when he showed up at the Society of Hospital Medicine’s annual meeting earlier this week to deliver one of the keynote addresses, he got a warm welcome from fellow hospitalists happy to see one of their own in a real position to make decisions about Medicare’s policies.

Dr. Conway gave the standard speech about what CMS officials are doing to transform the health care system. Then he turned to his hospitalist colleagues and gave them some things to do, too. Hospitalists need to partner with the hospital administration and their quality improvement teams. They need to understand their hospital’s performance data. And they need to take charge, he said, by leading multidisciplinary teams.

“We’re at a unique time in health care where we can drive change,” Dr. Conway said. “My challenge to you would be, please don’t sit on the sidelines.”

Dr. Patrick Conway

He urged the audience – hospitalists gathered in San Diego for continuing education and networking – to make an effort to lead some type of system improvement in their hospital. “I don’t actually care what it is, but work on some broader system changes in your local setting,” Dr. Conway said.

If hospitalists are looking for a reason to get out in front when it comes to system change, there are plenty of financial carrots and sticks coming very soon from the Medicare program. Dr. Conway outlined many of them, from Accountable Care Organizations to the readmission reduction program to the hospital value-based purchasing program. But the best reason to be active in changing the way the health system works is for the benefit of patients, he said. That’s the reason that Dr. Conway still works as a hospitalist nearly every weekend for free. “It’s about those families that you take care of,” he said.

– Mary Ellen Schneider

Leave a comment

Filed under Health Policy, health reform, IMNG, Pediatrics, Physician Reimbursement, Practice Trends

What if the Supreme Court Tosses Out the ACA?

Opponents of the Affordable Care Act are hoping that the Supreme Court will soon invalidate the law and put a permanent end to the federal government’s expanded role in health care. But one Capitol Hill watcher says the defeat of the ACA by the high court could lead to something conservatives would like even less – single-payer health care. Well, not anytime soon. But tossing out the law could help nudge things in that direction over time.

Norman J. Ornstein, Ph.D., an author and resident scholar at the American Enterprise Institute, said he could imagine a scenario where if the ACA were defeated, over time, Democrats would move to expand Medicare beyond the 65 and older crowd. Mr. Ornstein, who has a new book coming soon on the growing dysfunction in Washington, offered his two cents while speaking to a group of physicians at the Society of Hospital Medicine’s annual meeting in San Diego this week.

Protesters outside the Supreme Court in March. Photo by FRANCES CORREA/ IMNG Medical Media.

Another way that single-payer health care could become a reality is at the state level. Individual states might experiment with single payer-type programs along the lines of the Green Mountain Care program in Vermont, Mr. Ornstein said. Lawmakers in that state have enacted legislation allowing them to phase in a single-payer health care system over the next several years. But they have yet to hammer out details on how to pay for the program and it’s unclear how long it will take to move from the current framework of public and private insurance to a single-payer system.

– Mary Ellen Schneider

2 Comments

Filed under Health Policy, health reform, IMNG, Practice Trends

It’s March Madness!

Yep, that’s a shameless bid to appear higher on Google search results, but it’s also a pretty good metaphor for what’s happening in Washington in advance of the Supreme Court oral arguments on the Affordable Care Act–due to be heard March 26, 27 and 28.  Although speculation about how the Justices may rule has been going on for months, the gambling has reached a fever pitch.

ALICIA AULT/IMNG Medical Media

Next week is to Court Watchers as the Final Four is to legions of NCAA Division 1 basketball fans: The brackets have been completed; it’s just a question now of who will come out on top.

Conventional wisdom has the Supreme Court splitting along perceived “party lines” in a 5-4 vote either in favor of upholding the law, or against it.

But with the Justices taking on three separate, major issues within the law, Washington wonks, soothsayers, and legal eagles have gone into a frenzy of handicapping. Not a day goes by without a backgrounder or briefing that professes to have the best read on the tea leaves.

The Court, as is its wont, has shied from the limelight. Until today, it had not even determined how it would accommodate the legions of journalists (myself included) who will descend upon the courtroom to cover the historic arguments. Details are still being worked out, but one thing was not going to change: the Court has steadfastly refused to allow audio or video broadcasts of the proceedings. (Which means there cannot be any contests requiring a shot every time the challengers’ attorney, Paul Clement, utters “individual mandate.”) The Court is even banning–heaven forbid–cellphones. That means no pithy Tweets on Justice Clarence Thomas’ enduring silence.

This morning–at a briefing sponsored by Politico–came new predictions from an estimable panel of D.C. insiders: former U.S. Solicitor General Walter DellingerNeal Katyal, Al Gore’s co-counsel at the Court in Bush v. Gore,  Tom Goldstein, a former Court clerk and publisher of Scotusblog, Kevin Walsh, a former clerk to Justice Antonin Scalia, and Nina Totenberg, the veteran Court correspondent for NPR.

Dellinger, Goldstein and Katyal. ALICIA AULT/IMNG Medical Media

The Justices to watch, said Ms. Totenberg: Anthony Kennedy and Chief Justice John Roberts. They are both widely considered swing votes. Some have also have put Justice Scalia in that camp, “which I personally think is a crock,” Ms. Totenberg said. Mr. Katyal said that Samuel Alito could also be “in play.”

Will politics come into play? Justices “have a grasp of politics that defies imagination in terms of its inaccuracy,” said Ms. Totenberg, who, like the others discounted the idea that the Justices would be influenced–or motivated–to vote in one direction or another based on the prevailing political winds.

The panel was unanimous–except for Ms. Totenberg, who recused herself from making a wager–in its opinion that the Court would uphold the law, most likely in its entirety.

Mr.  Goldstein said he could not effectively imagine a victory by the law’s challengers. If the Justices threw out the Act, it “would lead to probably an array of attacks on different parts of the federal regulatory state because for the first time you would have had five justices that take very seriously limits on congressional power,” he said.

By the end of next week, the Court will likely hold one closed-door conference and a series of votes, said Mr. Walsh.

He and the other panelists went out on a limb, saying that the 5-4 prediction may no longer hold.  Mr. Goldstein said it could even be a 6-3 or 7-2 ruling upholding the law.

So who will write the opinion, expected to be issued in June? Mr. Dellinger predicted that it would be Justice Roberts. Mr. Goldstein, however, said this might be the rare case where the Court issues a per curiam opinionthat is, written in the name of the Court, rather than by any of the Justices. Interestingly, Bush v. Gore was a per curiam decision.

What is your opinion?

Alicia Ault

Leave a comment

Filed under Health Policy, health reform, IMNG, Polls, Practice Trends