News You Can Use-

AMA meeting: AMA to renew fight for Medicare balance billing
Some physicians say patients understand that they are struggling with practice costs and would accept balance billing.
By Damon Adams, AMNews staff. Dec. 3, 2007.

Honolulu -- Frustrated by Medicare pay cuts, representatives to the AMA House of Delegates directed the American Medical Association to call for national legislation to allow physicians to bill patients for costs Medicare doesn't cover.
At its Interim Meeting last month, the house adopted policy directing the AMA to devote its political and financial resources to initiate a measure at the appropriate time that would allow Medicare balance billing. The policy calls for introducing legislation that would end budget-neutral restrictions inherent in a Medicare physician payment structure that interferes with patient access.

In addition, delegates want the proposal to preempt state laws prohibiting balance billing and forbid inappropriate inclusion of bans on such billing in private physician-insurer contracts. The AMA would develop model language for doctors to use in insurance contracts that try to restrict balance billing of any insured patient.
With no permanent fix for Medicare cuts in sight, doctors said it makes sense to pursue a law that lets them bill Medicare patients the difference between reimbursement rates and what it costs to treat patients.

"What you see is a symptom of how difficult it is to maintain practices. It's physicians frustrated with reduced income," said AMA Trustee Rebecca J. Patchin, MD.

The action comes as doctors continue to fight an average 10.1% Medicare physician payment cut set to take effect Jan. 1, 2008. Doctors vowed to keep pressing for a solution to the Medicare pay formula, but they said balance billing is needed to offset pay cuts.

"It allows physicians to provide a fix to the Medicare crisis. Balance billing allows physicians to salvage the system," said alternate delegate Aaron Spitz, MD, a urologist from Laguna Hills, Calif.

In recent years, AMA policy has supported balance billing where allowed by law or contract. And the House of Delegates has asked for legislation to permit physicians to balance-bill regardless of the payer.

Dr. Patchin said the new move for balance billing would not divert the AMA from seeking a fix for the Medicare formula.

"It has reached a critical time. We need Congress to act on the [sustainable growth rate]," she said. "If Congress sets aside resources for adequate payment, there would not be a need for balance billing."

Some question changing the system
Medicare and most private insurers forbid or limit participating physicians from balance billing. Doctors who accept all Medicare patients cannot charge extra over Medicare's defined fee for covered services. Nonparticipating doctors who take Medicare case by case may balance-bill patients, but the extra charge is limited to a set percentage of the initial payment.

But some delegates at the Interim Meeting said the new policy may draw critics who say physicians are too concerned about money. They said a major push for balance billing would alienate seniors and distract Congress from working on the sustainable growth rate.

Others say elderly patients would suffer.
"A large number of them won't be able to pay. Please be careful what you wish for," said delegate Melissa J. Garretson, MD, a pediatrician from Stephenville, Texas.

Seniors group AARP opposes the practice and has fought against bills brought before Congress.

"AARP strongly opposes lifting or extending the current Medicare balance-billing limits. Prior to enactment of the 1989 Medicare physician payment reform, Medicare beneficiaries were spending billions of dollars out of pocket on excess physician charges. The balance-billing limits were put into place to protect beneficiaries from extraordinary costs," Kirsten Sloan, AARP's national coordinator of health and long-term-care issues, said in a statement.

"Lifting the limits is nothing more than a cost shift to patients. And it would only exacerbate out-of-control health care spending," she said.

But delegates said patients understand that physicians are struggling with low reimbursements and they believe seniors would be willing to pay more to keep their doctors. Some physicians have said they would be compelled to stop taking new Medicare patients if the reimbursement rate cut takes effect in January. An AMA survey this year found that 60% of doctors said they will limit the number of new Medicare patients if the cuts go through.

Responding to pleas from physicians, three delegations -- California, Florida and the District of Columbia -- introduced balance-billing resolutions to the AMA House of Delegates. When it was time to vote, delegates overwhelmingly supported a plan for national legislation.

"We're happy with the result. It's a solution in some ways," said delegate James T. Hay, MD, a family physician in Del Mar, Calif. "This has to be a long-range strategy for the AMA."

Dr. Patchin said the next step is to work with state and specialty societies to find a congressional sponsor for a bill. The policy the house adopted calls for the Board of Trustees to report progress by March 15, 2008, and at each semi-annual house meeting.

Rep. Michael Burgess, MD (R, Texas), said he is willing to author the legislation. Balance billing was part of a Medicare physician payment reform bill he proposed last year that failed to become law.

"It's something I believe in very strongly," Dr. Burgess said. "If the House of Delegates is interested, I'm interested, too."
With Medicare pay cuts less than a month away, balance-billing legislation is a must, doctors said.

"If not now, when is the appropriate time?" asked alternate delegate Corey L. Howard, MD, an internist in Naples, Fla

What has truly increased the cost of your healthcare?

New Medicare Regulations Adopted to Reduce Certain Hospital Infections and Medical Errors
Medicare Will Withhold Payments To Hospitals For Failing To Keep Patients Safe

WASHINGTON, D.C. – Under new Medicare regulations, hospitals will no longer receive higher payments for the additional costs associated with treating patients for certain hospital-acquired infections and medical errors. The new rules will give hospitals a powerful new incentive to improve patient care, according to Consumers Union, the nonprofit publisher of Consumer Reports.

“Every year, millions of Americans suffer needlessly from preventable hospital infections and medical errors,” said Lisa McGiffert, Director of Consumers Union’s Stop Hospital Infection’s campaign. “These new rules are a good beginning for Medicare to use its clout to mobilize hospitals to improve care and keep patients safe.”

Under the rules adopted by the Centers for Medicare and Medicaid Services (CMS), payments will be withheld from hospitals for care associated with treating certain catheter-associated urinary tract infections, vascular catheter-associated infections, mediastinitis after coronary artery bypass graft (CABG) surgery, and five other medical errors unrelated to infections (bed sores, objects left in patients’ bodies, blood incompatibility, air embolism, and falls). The new rules will go into effect in October 2008.

To comply with a 2005 law passed by Congress, CMS evaluated a number of serious, preventable health care acquired conditions and identified these eight for the first round of non-payment due to the high volume of patients affected, the high cost of treating patients, and the existence of prevention guidelines. The agency intends to consider other hospital acquired infections and medical errors for non-payment in future years.

The new Medicare regulations include protections to prevent hospitals from billing patients when payments are withheld and to minimize avoidance of patients perceived to be at risk for infections. “We are pleased that the rules clearly state that hospitals cannot bill patients for the amount that Medicare refuses to pay,” said McGiffert. “CMS will need to make sure these protections are enforced so patients are treated fairly. And the agency should be on the lookout for hospitals that try to game the system by falsifying codes to avoid nonpayment.”

Catheter-associated urinary tract infections are the most common infection developed by patients in hospitals. The Centers for Disease Control and Prevention (CDC) has reported that there are 561,667 catheter-associated urinary tract infections per year. According to a study in the American Journal of Medicine, the annual cost of urinary tract infections in hospitals is as much as $451 million.

Bloodstream infections are high in volume and cost, and are preventable. The CDC has reported that there are 248,678 cases of central line associated bloodstream infections every year. The Institute for Healthcare Improvement estimates that approximately 14,000 people die every year from central line-related bloodstream infections.

CMS failed to address the incidence of infections caused by methicillin-resistant Staphylococcus aureus (MRSA), a virulent antibiotic resistant bacterium. According to CMS, over 95,000 Medicare patients had MRSA infections in 2005, running up hospital charges of almost $3 billion. MRSA was not selected for nonpayment because of coding issues and because CMS does “not believe there is a consensus among public health experts that MRSA [infection] is preventable.”

“CMS needs to take strong action to curb the spread of this powerful superbug,” said McGiffert. “Many hospitals do not share the attitude that MRSA infections cannot be prevented and CMS should be on the front lines with them fighting this deadly and costly problem.”

Hospital acquired infections are a leading cause of death in the United States. The Centers for Disease Control and Prevention (CDC) estimates that 2 million patients suffer from hospital infections every year and nearly 100,000 of them die. Research shows that hospitals could prevent many infections through stricter adherence to proven infection control practices.

The financial costs associated with hospital infections are equally staggering. Dr. John A. Jernigan, Chief of Interventions and Evaluations at the CDC, has said that hospital acquired infections result in up to $27.5 billion in additional health care expenses annually. Medicare foots the bill for a big portion of infection-related health care costs. A 2005 report by the Pennsylvania Health Care Cost Containment Council found that Medicare was billed for 67 percent of the total number of patient infections reported by the state’s hospitals.

“Taxpayers spend billions of dollars every year covering the cost of patient infections,” said McGiffert. “Restricting Medicare payments for medical errors like patient infections will help ensure that the health care taxpayers pay for is safe and effective.”

A copy of the new CMS regulations can be found here (begin at page 290):
http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1533-FC.pdf

Ruling may unlock key data on doctors-An order to release Medicare files might help patients choose physicians. Medical experts say the records don't tell the whole story.

By Ricardo Alonso-Zaldivar, Los Angeles Times Staff Writer

Los Angeles Times August 30, 2007

WASHINGTON -- Whether it's a hernia repair or heart bypass, doctors with a lot of experience performing a given operation tend to have better results. The problem for patients in choosing a physician has been finding out which ones have the know-how.

Now a court ruling appears to open the way for consumer access to such information for the first time, potentially transforming the relationship between doctors and patients, as well as the business of healthcare.

In a little-noticed decision last week, a federal judge in Washington, D.C., ruled in favor of a consumer group that sued the Health and Human Services Department to allow disclosure of specific data about doctors from the Medicare claims database.

U.S. District Judge Emmet G. Sullivan concluded that releasing the data would be "a significant public benefit," and ordered the department to turn it over by Sept. 21.

With information on more than 40 million patients and 700,000 doctors, the Medicare database is far richer than any private insurer's. Though it does not have information on some doctors, such as pediatricians, who don't treat Medicare patients, it is considered the mother lode for data on those who treat adults, because Medicare recipients are a mainstay of most practices.

The database's usefulness has been limited by a decades-old government policy that protects the privacy of doctors, who fear the information could be used to micromanage the practice of medicine. But as the cost of medical care has skyrocketed, employers, insurers and consumer groups have pressured the government to open up Medicare's files on individual doctors.

Those files could reveal far more than how many times a year a surgeon performs a hip replacement operation. The data could also be analyzed to determine how a doctor makes crucial decisions on tests and procedures that determine both quality and costs. They would show which doctors fail to order prudent preventive tests. And they could indicate which ones order duplicative tests or unnecessary hospitalizations.

"These data will make it possible to develop measures that will be very helpful to consumers," said Robert Krughoff, president of Consumers' Checkbook, the nonprofit group that sued for the information.

"Someone who is thinking they need a knee replacement -- or a prostatectomy -- will be able to go on our website and see how many of these procedures their physician has done for Medicare patients," he added.

His organization -- which compiles ratings of a wide range of service providers -- sells its information to individual subscribers. But Krughoff said it intended to make the Medicare data available free of charge.

The lawsuit did not seek any identifying information on patients.

Some business groups said the ruling could be a turning point in the quest for the elusive balance between costs and quality, setting a precedent for the release of more detailed data.

"We're very excited that the court has ruled in this direction," said Helen Darling, president of the National Business Group on Health, which represents big companies. "Large employers have been trying to make information available on performance to consumers and to those who make purchasing decisions on which providers might be in a preferred network."

The Department of Health and Human Services has not decided whether to appeal the ruling. "We're in the process of reviewing the court's decision and evaluating our response," spokeswoman Christina Pearson said.

An appeal could be politically embarrassing for the administration, because President Bush and Health and Human Services Secretary Mike Leavitt have both campaigned for greater openness and consumer empowerment in healthcare.

"Not supporting this ruling would certainly be inconsistent with administration initiatives that favor price and quality transparency in healthcare," said Paul Ginsburg, president of the Center for Studying Health System Change, a research group. "This represents transparency on the quality side."

Moreover, support for opening up the Medicare database is building in Congress. Two unlikely allies, Sen. Hillary Rodham Clinton (D-N.Y.) and Sen. Judd Gregg (R-N.H.), a conservative budget hawk, introduced legislation in June to make the data available to research organizations around the country. Under current policies, researchers who use Medicare information cannot identify individual doctors.

In the past, the American Medical Assn. has voiced strong reservations about releasing the Medicare files. Spokeswoman Katherine Hatwell said the organization was closely reviewing the ruling and its implications.

Doctors are worried that Medicare files do not account for the severity of the cases that individual physicians may handle. Medicare files might show a higher-than-average number of patient deaths for a particular doctor's office. But that could be because the physician takes on the sickest patients.

As for the issue of how frequently doctors perform a given medical procedure, they point out there's a first time for every physician.

"Physicians are concerned that they will look bad, not because of their own shortcomings, but because their patients are difficult," Ginsburg said. "There are issues about using this type of information responsibly, and not using it unless you can do some significant adjustment for the difference in patients."

Krughoff acknowledges that such issues will have to be resolved as the use of the Medicare data becomes more sophisticated.

In the lawsuit, Consumers' Checkbook sought access to data on procedures performed by doctors in Washington, D.C., Illinois, Maryland, Virginia and Washington state. But Krughoff said the group has filed a Freedom of Information Act request for the same information from the remaining states.

"I think there's no question but that the judge's decision settles the matter," he said. "They'll have to give us all 50 states."

He estimated it would take a month or two after receiving the information to post it online