Medicare has given a warning to all physicians that they can not charge extra for covered services. One physician charged his patients $600 yearly for not only preventive (non-covered) services but also for things that are already covered such as coordination of referrals, extra time with the patient and a comprehensive assessment and plan for optimum health. The warning states that the CMS will be looking at these and if any abuse is found the physician will need to pay a fine and stop asking for the fees in the Medicare arena. For all those who do concierge medicine the best thing is to drop your Medicare patients from the concierge portion of the practice or only charge for the non-covered items. It appears that if there is a mixture of covered and non-covered, you will be liable. Top
The reports continue to filter in. The St. Louis Business Journal states that the area large oncology groups are beginning to turn away patients requiring certain chemotherapy drugs due to the Medicare price cuts. The patients will be forced into the hospitals to receive the drugs since the physicians would lose too much money if they continued to use the drugs in the office. The patients will also be saddled into paying the higher deductible by going to the hospital unless they have secondary insurance.
In hospital coding. the more complex the diagnosis the more money the hospital receives. In pneumonia, if the physician lists simple pneumonia as the diagnosis but treats as a complicated gram negative one the hospital may lose money. The physician may code as "probable" or "suspected", but usually will not if the culture is negative. This is the fault of the feds who have come down hard on those who have "upcoded". It is up to the hospitals to teach the physicians how to code correctly and legally.
California medical premiums are growing faster than the rest of the country. They rose 15.8% over the past year versus 13.9% for the rest of the country. The reason is the lack of competing health plans and the lack of tight control of patient care by the insurers. The flip side is that California is still cheaper than the rest of the country for its expenditure per person. More of the businesses are also cost shifting to the employees a portion of their healthcare costs. This is good in order for people to know and participate in healthcare decisions factoring in costs. If someone else is paying, there is no incentive to think twice before realizing the difference between want and need.
The HMOs are considering prior approval again. This contained costs in the 1990s but caused hatred towards the industry. Rationing of health care tends to do that. They are now either doing or considering doing preauthorization on chiropractic care, imaging, outpatient surgery, plastic surgery and physical therapy along with certain meds.
The HMOs of the sovereign state of Massachusetts is setting themselves up for another tea party. The costs for the HMOs are increasing and are their profits and they want to keep it that way. In order to do that they are foisting surcharges on those who want of need to go to the institutions or physicians that the HMOs believe are too expensive. This includes most teaching hospitals. This goes against the concept of web sites showing the best places to go for certain treatment, unless the website also is run by the HMO and they factor costs in at a very high level over quality. The employers, who made the mistake early in the game to pay for the medical care of their employees, will love the new rationing since it will keep the costs down at the expense of their employees. Top
The US Supreme Court is to rule on a case Texas case that stems from Cigna not allowing a patient more than one night in the hospital following a hysterectomy. She developed complications and wants to sue Cigna in state court. The issue is does ERISA preempt suing in state court or do the past decisions in the lower federal system stating one can sue in state court for either mixed or quality of care issues hold. The plan is arguing that if allowed to sue in state court, medical costs would increase, a spurious argument and not germane to the issue.
Highmark Blue Cross and Blue Shield in western Pennsylvania have stopped requiring primary care referral for specialist visits.
Aetna and CIGNA have both received failing grades by the New York Attorney General for not telling what they will and will not pay for. The companies gave no satisfactory responses to the questionnaire sent to them regarding what they tell prospective members. No HMO got an A and only one, Empire, got a B. Legislation is now pending in New York for non-compliance. Top
King/Drew Hospital in LA is finally getting some attention from the Board of Supervisors. The Board has fired the hospital administrator and four other top administrators with other to be disciplined. This is something that needed to be done a long time ago but the politicized Board did not do it. The supervisor in whose district the hospital resides continued to downplay the seriousness of the lies and faults of the hospital. She needs also to be replaced by the voters at the next election.
Drew/King is dumber than I thought. As the federal inspectors were there watching, they gave wrong meds or wrong dosages.
I'm not sure who is dumber, Drew/King or the feds. The feds have stated that the hospital is now in compliance with fed regs and will not take away their Medicare certification. The feds will require multiple people to check each medication prior to giving it to the patient and retraining of all who handle meds. The feds will send another team to the hospital in several weeks to see the progress in the remainder of their deficiencies. The supervisor in charge of the area where Drew/King resides states "we're not out of the woods". She doesn't say that she may be one of the reasons they were in the woods in the first place.
A member of the US House of Representatives whose district includes the hospital has met with a cadre of health officials, community members and others on the Drew/King debacle. It was a good selling point for her but did nothing for the hospital. One of the people at the meeting used the old line of not being given enough funding. That's true for all hospitals, not just those run by a county. Not all hospitals have the massive mismanagement that this political football has.
A group of physicians have purchased the Winona Hospital in the Indianapolis, Indiana area. The hospital was going under during its current ownership by Leland Medical Center in Texas. The physicians were so unhappy with the Texas ownership that the entire executive committee resigned en-masse this past fall. They will now be re-appointed. The physicians plan to continue the hospital in the near term as a community hospital, but since it is only 160 beds and is in the middle of the big hospitals of the area, don't be surprised to see it turn into a niche hospital.
Not to be outdone, the medical staff of Pennsylvania's MCP hospital is planning to purchase the hospital. The hospital is scheduled for closure June 30. The staff plans to have services that the prior owner, Tenet, removed be restored. The hospital needs about $30 million in renovations and if it closes will cost Drexel University hundreds of millions of dollars in federal funds. Drexel uses the hospital for its training program. Temple also wants the state to pony up so they can host a limited hospital with an emergency room to filter patients to their main hospital. The physicians want to keep it as a full service hospital.
Concierge medicine is not only for the physician but also the hospital. Florida Hospital in Orlando is starting a VIP Concierge Program. It is now free but includes quicker referrals and appointments with its employed physicians and going to the head of the line for specialized imaging services. The product is aimed at the 40-60 year old patient in order to get them used to coming to the facility. This may become a paid service in a year or so.
In a showing of what may happen when a hospital does not pay heed to its physicians, the largest OB group at Baptist Medical Center in Birmingham Alabama are now starting to go to its competitor, St. Vincent. The physicians wanted a free standing Woman's Health Center but only got a spruce up of the old part of the hospital. The OB group is also moving to a smaller office on the Baptist site indicating a long term commitment to St. Vincent's. Baptist had been approved two years ago for a new Woman's Center but did not follow through with the plans. Top
Up to now there has been only one organization responsible for all the immigrant nurses coming to the United States. There are now six other organization vying for the ability to compete against Commission on Graduates of Foreign Nursing Schools, a non-profit in Philadelphia. The Commission had been heavily criticized for poor customer service and for not doing its work fast enough. This has been the only company to be able to do this work thanks to pork by Pennsylvania Senator Arlen Specter. It now takes 6-9 months to investigate a nurse applicant by the Commission. This will be reduced if there are more companies able to do the work. The Commission has a significant hold on visas and is in very tight with many state nursing boards.
In an op-ed piece in the San Francisco Chronicle, the executive director of the California Nurses Assn. is gloating over the new nurse ratio rules. The good part of the legislation is the state has attracted a large amount of nurses to care for the patients. The bad part is the costs for the law is and has pushed some hospitals that were on the precipice to close. It also helped Tenet decide to leave the state which will force other hospitals to close if not sold.
The militant CNA also is complaining about Sutter Delta for not hiring RNs to fill the need ratio slots. What they forget is the law that they helped to write states that the hospital may have a 50% RN, LVN ratio. Sutter Delta has hired LVNs and RNs as required under the law. The CNA has now targeted Sutter for their tiff. If they don't like what is happening they need to return to the Democratic legislature and get a new bill that now may be vetoed by a non-rubber stamp Republican Governor. To date there have been 114 reported cases of non-compliance and 3 citations.
State Senator Shiela Kuehl, the Democratic author of the law does not believe a nursing shortage exists. This is not an uncommon type notion for the senator. She continued on to say that since many nurses had left hospitals for private nursing because the situation was so dangerous that they couldn't sleep at night they would not return since there are safe ratios. She left out the problems of the high average age of nurses, the lack of training of nurses, the good pay, benefits and hours of private nursing and most other things that don't fit into her small mind. Top
Maryland may be changing its tune. The Governor and the Senate are considering malpractice reform. It is doubtful if the Senate can agree on the terms be the end of this year's session, next month. The Democratic controlled houses will not pass anything with caps or that will reduce the trial lawyer's take.
In Illinois, physicians are starting to go bare. One physician asks his patients to sign a form acknowledging that they know he does not have malpractice insurance. The hospitals continue to have rules that require malpractice insurance but the physicians are trying to change that. The physicians can get a reduction in their malpractice premiums of up to 30% by taking courses in risk management. The more courses they take the more discounts they get.
The Illinois med-mal carrier ISMIE has been criticized for raising rates at the same time it reports a large profit and surplus as well as hiking the pay of the insurer's executives. This was not a politic move by the insurer and will cost them in the legislature.
Illinois has also put the kibosh on non-economic caps for med mal cases. The reason is the trial lawyers controlled Democratic state Senate and Governor.
Florida is going to attempt again to get malpractice reform passed. The proposed bill by the legislator who is running for the US Senate and wants money from the physicians to help that campaign, would limit the amount that attorneys could receive in a med mal case to $250,000. This will not get out of committee.
Pennsylvania has reported a substantial drop in med mal suits in 2003 over 2002. The most likely cause for the drop is that attorneys who usually wait until the last moment to file suits, filed early due to the prospect of med mal reform in the state. It is interesting that the largest drop in cases filed was in Philadelphia where the new rules were not going to allow venue shopping. Those cases were actually kept in the outlying venues.
The Pennsylvania Governor has called for a panel to mediate malpractice cases. In a strange statement, the Governor wants the hospitals to offer pre-trial settlements to patients for the physicians being accused of malpractice. This would be non-binding and voluntary. Some hospitals in the state already use this type system. He also is proposing judges be given more leeway to reduce payments to plaintiffs. His last proposal is the caps on attorney fees.
The Connecticut physician who rallied at Hartford were told that they will not get the non-economic caps to help them, in spite of the pleas of the Governor. The trial Attorneys state that Connecticut still is fourth in the nation in physicians to patient ratio so there is no need to fear physicians leaving the state. What they forget is the numbers are raw and do not reflect those who have or will leave or retire but keep their state license. It numbers also don't reflect those physicians who remain who will cut back their practices to only doing those procedures that will lead to a decrease in their malpractice premiums.
Wyoming's largest malpractice insurer is leaving the state. OHIC Insurance will stop writing insurance in Wyoming in August. It currently insures about 43% of the state's market.
One would think that if a state senator wanted to freeze malpractice rates for a year that the hospitals and medical associations would jump for joy. There is no joy in Ohio. The hospital association has come out against a one year moratorium in med mal rate increases and the the Ohio State Medical Association is still assessing the issue. The state insurance commissioner is also against the idea. The fear is the moratorium will drive away some med mal carriers in the state. The new bill would require med mal carriers to then justify to the insurance commissioner their requests for premium increases. In the last 15 months the insurance commissioner has not rejected any requested rate increase. Top
Steve Twedt, the reporter from the Pittsburgh Post Gazette who initially ran the articles on disruptive physicians, has a new article focusing on California. The article states the California Medical Association is following Oregon and will look into the unfair profiling of physicians who speak out for patient care. This was brought to the forefront when Community Hospital in Ventura allowed a radiation therapist to practice who had no privileges granted by the medical staff. The California Hospital Association is against the proposed Medical Association bill since it is against state law to retaliate against physicians who advocate for their patients. Of course, when this occurs in the state the Hospital Association looks the other way.
An interesting story in the New York Times discussed the fall of anatomy classes in medical school. There seems to be more teaching using anatomical models produced by CT and MRI images than by actual student dissection. The story goes on to discuss some of the schools that are continuing to do cadaver dissections and the way they honor those they are dissecting. I remember many years ago when I taught at a University, the students were no longer required to take anatomy at all. Their performance showed their deficiencies.
It does rain in Indianapolis in the summer time. A local employer coalition is attempting to put together a report card on the local physicians. The physicians would need to pass the rating system in order to be allowed to treat the coalition's members. Top
The FBI raid ed three southern California outpatient surgical clinics for illegal billings for unnecessary surgical procedures. The clinics have been accused of paying patients to have the procedures and having them paid by point of service contracts. Cappers had flown patients and the spouses to California from around the country, paid for their hotel rooms and food along with spending money to have some minor procedures performed and the clinic would then bill the insurers major money for the procedures. Top
Please see Recent Legislation.
The Government has released the information on who is a specialty hospital. This is on this update under Recent Legislation. The guidance is helpful to all concerned. The guidance follows the Medicare Modernization Act which created the moratorium. It also allowed some wiggle room for more hospitals to be approved now and not having to wait the now less that 18 months.
The Association of Ambulatory Surgery Centers has reported that the hospitals of the country own part of 44% of the ASCs in their geographic area. Physicians had partial ownership in 83% and in 19% this was with a physician hospital partnership. This goes against the government report that showed only a 1% ownership by hospitals.
God help the lawyers because they need it. In New Albany, Indiana, a new specialty hospital is being fought by the general hospital. The fight is whether or not the new hospital is banned under Medicare or may go forward. The process hinges on the definition of zoning. The New Albany Planning Commission had unanimously approved the plans by the November 18 cut-off date but the Board of Zoning did not give its rubber stamp until January. The hospitals will spend big bucks on their attorneys but it will not stop the new hospital. The smarter and cheaper way was just to ask the Feds for a rapid response, which they have said they will give. Top
The California Medicaid Auditor does accounting like Enron. In order to show how good the Medicaid Fraud is, she reported the total saved which included all the legitimate claims by the fraudulent physicians. If you take that number away, the savings do not add up. Top
DISCLAIMER: Although this article is updated periodically, it reflects the author's point of view at the time of publication. Nothing in this article constitutes legal advice. Readers should consult with their own legal counsel before acting on any of the information presented.