And take that!!

The National Labor Relations Board is suing an ambulance company for firing a worker. The company fired the worker after she posted derogatory comments about her supervisor on FACEBOOK (TM), from her home computer.

The company says the employee was fired for multiple reasons.

The NLRB says the company violated the employee's rights, and that further derogatory comments from her and other employees were "concerted activity" protected by federal labor laws.

The new and marvelous age of technology.

SGR Cuts for Physicians

Unless Congress intervenes, cuts in December and January will lower the average Medicare physician reimbursement by about 30%. Primary care physicians will see a small increase.

Dropping Medicare rates down toward Medicaid rates will do severe damage to some practices. Given the fixed/variable cost structure of physician practices, short term the only practical cuts are in staffing (and that is tough) and physician incomes. Are some physicians gaming the system? Sure.

Conspiracy theorists believe the administration wants to destroy most private practices and drive docs into hospital employment relationships. This could have some benefits, but could also do severe damage to quantity and quality of care, not to mention many hospitals do a lousy job of managing physician practices. This sort of integration can be done fast or right, but not fast and right.

Yes, we need health care reform. Fast and stupid is not the reform we need.

Added to the Document Archive

Records retention grid - and more to be added very soon.

Any requests? If we have a policy, procedure or checklist we will add it - or write it.

healthcarethinktank@gmail.com

Document Archive

Seminar handouts, consulting checklists, white papers and much more will be gradually accumulated in our new Internet publishing site at www.issuu.com.

healthcarethinktank document archive

Compliance: "Leave the gun, take the cannolis" (1)

The changing face of health care fraud is becoming more evident, especially fraud committed by non-providers - such as non-existent durable medical equipment shops.

These groups often combine computer hacking, identity theft and bill-and-run phony front offices.

Now a little bit of a new twist.

Today (October 13th) the federal government arrest 73 people charged with racketeering for creating more than 100 phony clinics in more than a dozen states and billing Medicare and Medicaid something like $163 million. The crooks, allegedly with an Armenian "godfather" in charge, stole the identities of both doctors and patients before blitzing the feds with phony billings from non-existent clinics. The "godfather" is in lockup today.

Meanwhile the feds are auditing legitimate providers with contract auditors and cranking up requirements for compliance work. Maybe the feds should pay more attention to internal controls before paying crooks?

(reported via several major wire services)



(1) from The Godfather (part 1)

The (Premium) Stuff is Hitting the Fan

Many companies are on calendar year contracts for health insurance. New quotes are often delivered in October, decisions to keep or switch policies are made, and an open enrollment period (sign ups for new coverage and changed coverage) takes place in November so paperwork can be in place by January 1.

It is no secret premiums are going up, and some are going to way, way up. This will likely induce recession-battered employers to pass more costs on to employees, effectively a cut in net pay for employees. The memos will be passed through organizations in the next few weeks, and employers will have meetings with grumpy employees.

PPACA (Obamacare) requires more lives covered in the group and more services (especially preventative) covered by the plan. This plus the usual issues of utilization and cost are driving up premiums.

This was all very predictable.

Some day these changes may start to bend the cost curve, but probably not soon enough for President Obama.

Do not stand in front of the fan.

Comparative Effectiveness Research, Gender and Emotion

A key cost bending feature of PPACA (Obamacare) is comparative effectiveness research (see http://www.hhs.gov/recovery/programs/cer/index.html).

This research is designed to apply statistical, economic and clinical analysis to care and treatment to encourage effective care and block ineffective treatments.

It is highly likely, based on current research, the statisticians will recommend less screening and much less treatment for prostate cancer. As one doc said, "almost all old men die with prostate cancer, almost none of them die from prostate cancer." Screening will likely be focused on younger men and more aggressive forms of the cancer.

With men being somewhat nonchalant about such matters, and prostate cancer being something less than a celebrity telethon issue, it is unlikely there will much of a fuss. Money can be saved and the resulting increased mortality will be slight.

At the same time, current recommendations about breast cancer are suggesting a lot less mammography, and there is an uproar.

Breast cancer hits many women, hits many younger women, and the results are horrifying. The blowback from advocacy groups has been and will be fierce.

So can we get past gender and emotion to become more efficient and effective? Whatever sounds good in the abstract, many of us will go with emotion.

Obama Administration Gets "Tough" With Insurers

DHHS Secretary Sebelius has lambasted the private health insurance industry in a letter to the industry's trade association (I'm not a big friend of health insurance companies, FWIW). From the letter:

"There will be zero tolerance for this type of misinformation and unjustified rate increases."

The issue is premium increases and the cause of the premium increases. Most of us are not in love with insurers, but we should stay connected to reality.

PPACA (Obamacare) requires more lives on some policies and more coverage broadly, so no wonder premiums will be going up in the short and near term (some of us predicted this).

There is little likelihood of bending the cost curve for at least five years, as the various and numerous programs in Obamacare phase it and ramp up. And then, who knows.

Understanding that politicians must be nature take care of politics, this seems a little shrill and over the top.

The official version.

http://www.hhs.gov/news/press/2010pres/09/20100909a.html

Nursing Shortage

As Labor Day approaches it is a good time to think about health care labor issues, some good news, some bad news.

A phenomena many of us have noticed over the years (hard to exactly quantify though) is that recessions pull nurses back into the labor market. Nurses (about 94% female) often have husband or significant others who lose jobs or hours.

Also, some of the staffing pressure is off at the hospital level because elective procedures are down and that takes pressure off the nursing staffing.

Recessions are not the desired means of correcting the shortage though.

The discussions of shortages go back at 20+ years, and amazingly little progress has been made during that time.

There are some new and expanded programs, but a big problem now is the lack of nursing faculty. Unlike many PhD qualified professors, nursing professors are in big demand for management positions, usually in hospitals and health systems. So we are cannibalizing our own nursing pipeline.

University nursing programs are labor intensive, resource intensive and not nearly as prestigious as producing more MBAs, lawyers and economists.

While universities will get into bidding wars over top flight business, science or law professors, the willingness to play in the nursing salary market seems muted (perhaps if nursing was 94% male???).

The shortage will persist; the average age of RNs is climbing, the boomer nurses are heading for the exit while the boomer patients are becoming seniors, clinical skill requirements are accelerating, tighter reimbursements leave providers with less flexible budgets, and at times up to half of all licensed nurses are not working in direct care nursing - - all which seems to be a perfect storm.

We can send a man to the moon, but we can't figure out how to solve this problem in a country where lots of people need new careers (and yes, lots of people are not suited for nursing). Maybe when we have to shut a lot of hospitals?

HIPAA Horrors

This has been a week for HIPAA horrors.

A reporter dropping some trash at a landfill in Massachusetts stumbled on a huge pile of medical records. It seems a former billing company for pathologists who served four hospitals had dumped the records without bothering to shred them. Now the hospitals and pathologists are on the hook – ouch.

Then a psychiatrist on the west coast left his laptop on the back seat of his car, and to his surprise (?) it was stolen, and the laptop contained demographic and billing information on thousands of patients.

Violating HIPAA at the Speed of Light

Rarely does a week go by without a story of how "social media"** have caused problems for an employer, often because of posting confidential information, photos or just nasty comments about some phase of the business operation or co-workers.

In health facilities the stakes are much higher.

Now is the time to develop policies and educate the staff, BEFORE something bad happens.



** Facebook, MySpace, Twitter, and of course email is also a problem.

IDS - Wave of the Future?

Among those who ponder the technical aspects of health care reform, there is strong sentiment for more use of Integrated Delivery Systems (IDS) in delivering health care.

This is hardly a new concept, being decades old, and it may well be the concept of the future.

The first big IDS wave occurred in the early to mid-90s, as physicians and hospitals tried various medical service organization (MSO) models; essentially the hospital owned the physician practices. Many of these deals were disasters, some worked, some evolved into something that worked.

The idea is that if a central entity (an insurer, a hospital, or a hospital network) owns and coordinates services there will better care coordination and cost savings.

The successful integrations so far have largely focused on family practice, internal medicine and ob-gyn (the OBs assistance with malpractice premiums and 24/7 coverage issues).

An interesting change is surfacing, the acceptance of specialists and surgeons into IDS models. Historically there has been a great deal of friction between these docs and the hospitals.

Why the change? Fear of dire economic consequences of staying in a traditional group practice model. Preliminary numbers from the 6/30/2010 residency class is that for the first time, a majority may opt for IDS employment rather than group practice. There are also reports that young docs are more concerned with life balance issues than previous generations.

So, any problems?

Hospitals are notoriously bad at managing physician practices, physician contracts must be structured carefully, physician productivity sometimes drops off with a steady paycheck, and the process of merging practices and/or converting ownership is a great deal of complex work at no small cost. Also, making this work in rural areas is tough.

Biggest question, will IDS on a large scale really cut costs? Or just reshuffle the deck chairs?

Yes - No - Yes - No - Maybe - Sorta - Someday

Medicare Fee Ordeal - Continued

As of Friday the Senate has passed a six (6) month patch to counter the Sustained Growth Rate formula cuts to physician fees.

The House will consider the patch next week, and is likely to pass the necessary legislation.

CMS contractors will process claims from June 1 forward - someday.

Stay tuned.

FTC Red Flags Delayed Again

The Federal Trade Commission has delayed the "red flag" identity theft rules for (most) health care providers. The rules originated in the Fair and Accurate Credit Transactions (FACT) Act of 2003.

The act defines most medical providers as creditors.

The new effective date is January 1, 2011.

Stay tuned.

3/21/2010 10:48 pm - A New Era Begins

An editorial:

The passage of the health care reform bill is a major milestone for U.S. health care services.
With passage, we will need to unravel the bill and the real story and prepare for the intended and unintended consequences of this massive effort.

The legislation is neither as bad as the Republicans make it out to be, not as fabulous as the Democrats claim. The bill changes the health care system to an amazing depth and breadth, and despite the proclamation of economists, politicians and policy wonks, we do not really know the full impact of the bill.

Reform is needed, we will soon be hitting the point at which employers have trouble providing health insurance to employees at an affordable price, the alternatives being dropping coverage or taking more from employees pockets.

President Obama will be hammered by the political right for going too far too fast, and by the progressive left of his own party for being timid. The left wanted a single payer system, was willing to settle for a public option, but left the table with only hope reform will be revisited, as it will.

The amount of misinformation, overgeneralization and plain old hot air tossed around during the debate make a calm analysis difficult, and will leave citizens and patients confused and alarmed, probably more than required. The bill is full of slow phase-ins and long transitions as we attempt to turn around one-sixth of our economy and attempt to attain several seemingly contradictory goals.

A great deal of the debate has focused on the budget impacts, and specifically the positive or negative impact on the deficit over a ten year span. The bill is full of wiggles and gimmicks, and as the vote drew near the Congressional Budget Office (CBO) estimated a positive deficit impact of about $140 billion in ten years.

Truth be told no one has any real idea what the bill will do to the deficit over ten years. Anyone who has studied the history of Medicare and Medicaid knows the legislative budget estimates tend to melt in the face of annual politicking and lobbying.

There are problems needing immediate attention. State budgets, hammered by the recession will have to be cut Medicaid benefits, a backwards step. Medicare physician reimbursement formulas, problematic for a decade, are being patched again while Congress dances around a permanent solution. Private insurers and employers will have to adjust quickly to new regulations and cost structures. Changes in Medicare are inevitable.

We can improve coverage and contain cost, but the reforms have to be constructed so carefully it is unlikely any political process has or will do so.

Now we know when the journey begins and the direction it is going. The details will be tough to work out, and there are many battles ahead, but decision making improves as certainty increases. We may get a good place, but not without many bumps and bruises.

Game On! Again

This week President Obama introduced (finally) the Obama health care plan.

The plan, close to the Senate version but with concessions to the House version, will be pushed hard by the administration and Democratic leaders in the Congress.

The plan is long, complicated, has many moving parts and is liekly to change significantly.

More details to follow as we parse the plan and Congress begins to move.

While Rome Burns Nero Fiddles - Health Care Edition

While the House and Senate were trying to overhaul the entire health care system, key Medicare regulations were left in limbo. Those provisions are still in limbo.

Medicare physician reimbursement based on Sustainable Group Resources (SGRs) have been controversial and generally considered unworkable since being passed. The solution has been an annual fix rather than a permanent fix. The House bill had a permanent fix, but went nowhere.

As a result of not being fixed, some physicians will see draconian cuts in Medicare reimbursements as of March

Primary care docs will see a small increase in rates. Or there may be a fix, or maybe not.

Physical therapists who provide Medicare services are now subject to a cap, amounting to rationing, for elderly patients. This capping system was instituted in 1997 but an annual fix has prevented implementation. Now that too is in limbo, and therapists may be “donating” services in 2010, while waiting on an answer. If the cap remains, services will have to be rationed..

Seniors are very dependent on various forms of therapy to regain mobility and self-sufficiency after fractures, surgeries and strokes. Would we prefer nursing home placement instead?

If health care reform enlarges the role of the federal government, and this is how the feds do business, this could prove interesting.

Game On!

This month will be a major month in the history of U.S. health care, whatever happens.

The House and Senate will attempt to reconcile their bills, with the future of reform in the balance.

Stay tuned!