Nurse practitioners are making inroads in some states in getting more clinical authority but are still blocked in some states by physician groups fearing that giving nonphysician clinicians a wider scope of practice would cut into the income of doctors, who remain by far the highest paid in the world.
Advanced nurse practitioners have been fighting for years for the right to write prescriptions and operate practices without an agreement with a physician.
The pressure to expand the scope of nurse practitioners’ practice has intensified with studies saying that many millions of Americans live in areas with primary-care physician shortages.
A wider scope of practice would include, for instance, letting nurse practitioners diagnose patients, order tests, complete death certificates and initiate involuntary psychiatric commitment for unstable patients without a supervisory relationship with a physician.
Modern Healthcare says that “Physicians say advanced nurse practitioners can help alleviate the primary-care shortage, but only if they are a part of a coordinated team led by a doctor. ”
Robert Wergin, M.D., chairman of the American Academy of Family Physicians told the publication:
“What we’re for is team-based care where it’s the right provider, the right care at the right time. Everyone contributes to the care, but we’re not necessarily interchangeable.”
“Independent practice and team-based care take healthcare delivery in two very different directions,” an American Medical Association spokeswoman added. “One approach would further compartmentalize and fragment healthcare delivery, while team-based care fosters greater integration and coordination.”
Medscape reports that new rules from CMS say that “physicians must not only return Medicare overpayments within 60 days of identifying them but also actively look for overpayment through self-audits and other forms of research….”
“If a physician fails to hand back overpayments within 60 days, he or she risks getting sued by the government under the False Claims Act (FCA).”
Many physicians, already drowning in paperwork, will not be pleased by this latest CMS mandate.
“This requirement would be extremely burdensome for physicians as it would impose a boundless duty to troll medical records in search of innumerable vulnerabilities,” the American Medical Association and dozens of other medical societies wrote CMS in 2012.
“CMS did not cut organized medicine any slack in its final regulations, but instead said what physicians did not want to hear. The agency also warned that some healthcare providers might avoid self-scrutiny for the sake of not discovering money they would have to return,” the publication reported.
“We disagree that this rule creates a requirement for any formal compliance plan or audit strategy,” CMS said. “Rather, it requires that providers and suppliers maintain responsible business practices and conduct a reasonably diligent inquiry when information indicates that an overpayment may exist.”
Wanda Filer, M.D., president of the American Academy of Family Physicians, one of the signatories to the 2012 letter to CMS, told Medscape that she hopes the agency will “interpret ‘clear duty’ very gently,” lest, as the publications put it, “physicians find themselves with more administrative work that reduces face time with patients”
“Patients have one clear duty, and that’s taking care of patients,” Dr Filer told Medscape. “CMS has a clear duty to protect the Medicare trust fund. How we strike the balance…will be the art of this.”
A bipartisan group of U.S. senators are introducing a bill to expand telemedicine service through Medicare benefits.
Modern Healthcare reports that the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act (PDF), “would expand the use of remote patient-monitoring for some patients with chronic conditions, increase telemedicine services in community health centers and rural health clinics, and provide basic telemedicine benefits through Medicare Advantage.”
Backers also tout the measure as having the added benefit of helping providers meet the goals of the Medicare Access and CHIP Reauthorization Act and the Merit-based Incentive Payment System.
The CONNECT Act is supported by several industry groups, including America’s Health Insurance Plans, the American Heart Association and Kaiser Permanente.
“This bill would ensure that patients and their physicians are able to use new technologies that remove barriers to timely quality care. Importantly, the bill would maintain high standards whether a patient is seeing a physician in an office or via telemedicine,” said Dr. Steven J. Stack, president of the American Medical Association.
When Charles Thompson of Greenville, S.C., checked into the hospital one July morning in 2011, he expected a standard colonoscopy. He never anticipated how wrong things would go.
Partway through, a doctor emerged from the operating room to tell Thompson’s wife, Ann, that there had been complications: His colon may have been punctured. He needed emergency surgery.
Thompson, now 61, almost died on the operating table after experiencing cardiac distress. His right coronary artery required multiple stents. He also relies on a pacemaker. “He’s not the same as before,” said Ann Thompson, 62. “Our whole lifestyle changed — now all we do is sit at home and go to church. And that’s because he’s scared of dying.”
When things like this happen, questions arise: Who’s responsible? If treatment makes things worse — meaning that a patient needs more care than expected — who pays?
It depends.
Despite provisions in the Affordable Care Act that put added emphasis on quality of care, entering the hospital still carries risk. Whether because of mistakes, infections or plain bad luck, those who go in don’t always come out better. More than 400,000 Americans die annually in part because of avoidable medical errors, according to a 2013 estimate published in the Journal of Patient Safety.
In 2008, the most recent year studied, medical errors cost the country $19.5 billion, most of which was spent on extra care and medication, according to another report. If a problem such as Thompson’s stemmed from negligence, a malpractice lawsuit may be an option. But lawyers who collect only when there’s a settlement or a victory may not take on a case unless it’s exceptionally clear that the doctor or hospital was at fault.
That creates a Catch-22, said John Goldberg, a professor at Harvard Law School and an expert in tort law. “We’ll never know if something has happened because of malpractice,” he said, “because it’s not financially viable to bring a lawsuit.”
That leaves the patient responsible for extra costs. Ann and Charles Thompson maintain that he experienced an avoidable error. The hospital denied wrongdoing, she said, but the physician’s notes indicated that they had been advised of the risks of the procedure, including injury to the colon.
The Thompsons tried pursuing a lawsuit but couldn’t find a lawyer who would take the case. The hospital and the doctor declined to comment, with the hospital citing patient privacy laws. Because of his heart problem, which led to the loss of his specialized driver’s license, Thompson lost his truckdriving job. He lost the health insurance he had through his job, depriving him of help in paying for follow-up care.
The couple paid close to $600,000 out of pocket, depleting their life savings. They struggled to pay other bills until Thompson was awarded disability benefits, his wife said. “You would expect if [health-care providers] make the mistake, they would make you whole,” said Leah Binder, president of the Leapfrog Group, a nonprofit organization that grades hospitals on their record of preventing errors, injuries, accidents and infections. “But that is not what happens. In health care, you pay and you pay and you pay.”
There’s no single rule for how hospitals handle the cost of care when patients have bad outcomes and fault is disputed, said Nancy Foster, vice president for quality and patient safety at the American Hospital Association. Some hospitals have rules requiring that a patient be told right away if something happened that shouldn’t have and, to the best of the institution’s knowledge, why.
Typically, those rules stipulate that if the hospital finds that it erred, the necessary follow-up care is free. Hospitals may not have an obvious financial interest in admitting guilt, though research suggests that patients are less likely to sue when hospitals are transparent about medical mishaps.
“If the [need for further] care was preventable, we’re waiving bills,” said David Mayer, vice president of quality and safety for MedStar Health, which operates 10 hospitals in the Baltimore/Washington area.
Virginia’s Inova Health System has a similar policy, said spokeswoman Tracy Connell. Most hospitals don’t have such rules, said Julia Hallisy, a patient-safety advocate from California.
That may change: A number of professional and safety groups are urging more hospitals to adopt them. Supporters include the American College of Obstetricians and Gynecologists, the American Medical Association, Leapfrog, the National Quality Forum and the Joint Commission, which accredits many health-care organizations. The federal Agency for Healthcare Research and Quality is also on board.
But even when they tell patients that something went wrong, hospitals may say it was unavoidable. Then, patients often pay for the consequences, directly or through their insurance. Determining error can be straightforward, Mayer said, in such instances as misdiagnosis or operating on the patient’s left leg when his problem was with his right leg.
Other times, providers follow correct procedures but things go wrong. Then, hospitals can deny culpability. “Some things happen, and it’s hard to tell if it could truly have been avoided,” Binder said. If hospitals don’t agree to pay for unexpected care, employers might push them to do so because absorbing such costs might eat into the firm’s profits.
On average, a privately insured patient cost about $39,000 more — $56,000 vs. $17,000 — in hospital bills when surgery led to complications than when it did not, according to a 2013 study in the Journal of the American Medical Association.
People with employer-based insurance — 147 million Americans this year — who have experienced complications or otherwise gotten worse while in the hospital should contact their benefits offices, especially if they can show hospital error, Binder said. If that doesn’t pan out, insurance plans may step in.
When insurers add hospitals to their networks, they sometimes stipulate how to handle certain errors. For some mistakes, the hospital may provide necessary follow-up care for free, part of a “bundled payment,” said Clare Krusing, a spokeswoman for America’s Health Insurance Plans, a trade group. For that to apply, complications must clearly stem from bad treatment. In other situations, patients can complain through the insurer, which should work with the hospital to determine who’s responsible.
Patients, Krusing said, shouldn’t pay for what’s out of their control. And if the hospital doesn’t provide financial assistance, insurance should cover these unexpected expenses once the patient has met his or her deductible.
“Patients don’t normally think about these issues — and who would? They don’t think of any of these issues until they’re right in the middle of it,” patient-safety advocate Hallisy said. “At that moment, they’re completely shocked and overwhelmed to think that this is how this works.”
For generations, physicians have been trained in basic science and human anatomy to diagnose and treat the individual patient.
But now, massive stores of data about what works for which patients are literally changing the way medicine is practiced. “That’s how we make decisions; we make them based on the truth and the evidence that are present in those data,” says Marc Triola, M.D., an associate dean at New York University School of Medicine.
Figuring out how to access and interpret all that data is not a skill that most physicians learned in medical school. In fact, it’s not even been taught in medical school, but that’s changing.
“If you don’t have these skills, you could really be at a disadvantage,” says Triola, “in terms of the way you understand the quality and the efficiency of the care you’re delivering.”
That’s why every first and second year student at NYU Medical School is required to do what’s called a “health care by the numbers” project. Students are given access to a database with more than 5 million anonymous records — information on every hospital patient in the state for the past two years. “Their age, their race and ethnicity, what zip code they came from,” Triola lists, as well as their diagnosis, procedures and the bills paid on their behalf.
The project, funded in part by an effort of the American Medical Association to update what and how medical students are taught, also includes a companion database for roughly 50,000 outpatients. It’s called the Lacidem Care Group. (Lacidem? That’s “medical,” backwards). It contains data from NYU’s own faculty practices — scrubbed to ensure that neither the patients nor the doctors can be identified. Students can use tools provided by the project to “look at quality measures for things like heart failure, diabetes, smoking, and high blood pressure,” says Triola. “And drill down and look at the performance of the practice as a whole and individual doctors.”
Some students have taken to the assignment with relish. Second-year student Micah Timen is one. Timen likes numbers. A lot. A former accountant before applying to med school, he keeps a spreadsheet to track his study hours before a test. An upcoming test is on the digestive system. “So I know I have 18 hours and 40 minutes left to make sure I feel comfortable walking into my exam,” he says.
For his project, Timen wanted to know if the cost to patients of hip-replacement surgery around the state vary as much as the cost of a fast-food hamburger. Timen says they tried comparing hip replacement costs using The Economist magazine’s famous Big Mac Index, which measures purchasing power between currencies. “But when you call McDonald’s, they don’t give you prices over the phone,” he said. So he tried Plan B: “Burger King gave it to me.”
Using his “Whopper Index” instead, Timen found, not surprisingly, that the price of a giant burger sandwich is higher in New York City than, say, Albany. So, too was the amount patients paid for their hip replacements. But the margin was much wider for health care than for hamburgers, meaning patients are paying more in some places than simple geography would suggest. Timen says he’d like to explore why that might be, “but unfortunately med school is a little bit time-consuming,” so that may have to wait.
Still, it turns out the classes appeal not just to data “junkies,” like Timen, but also to those who were not already steeped in crunching data.
“I really have no statistical background,” says Justin Feit, also a second-year student. “I don’t even know how to use Excel well.”
So Feit was partnered with Jennifer Lynch, who already has a PhD — in physics. She says that if medicine wasn’t moving in the direction of more data interpretation, “I don’t know if I would have gone into medicine.”
Together Feit and Lynch looked at the rates of cesarean births around the state – and, like the cost of hip replacements, found that C-section rates varied widely. But their project will get more than just a grade. A faculty member at NYU is using it as part of a bigger research project headed for publication.
Triola says he hopes that will happen more and more.
“With literally millions of records, these in-class student projects often involved more patients than the published literature. It’s incredible,” he said.
And the concept of having students learn to use health data is catching on quickly. Triola says NYU is offering its database and program to other medical schools; seven are already incorporating it into their curriculum.
Modern Healthcare says: “Health information technology cognoscenti predict most providers of size—large hospitals and health systems, large physician groups and large health plans—will swim right along in a sea of far more numerous, complex and very specific new codes.”
“And after three government-induced delays totaling four years, most providers should have been ready.”
Still, insurers might be forced to delay reimbursements if codes aren’t submitted properly.
“The American Medical Association, numerous state medical societies, and other physician groups had fought the conversion for years, almost to the bitter end. The AMA didn’t throw in the towel until July, cutting a deal with the CMS in which physicians were given one year’s worth of wiggle room via a pledge by the agency not to bounce Medicare claims incorrectly coded.”
The Globe reports that “Federal law allows pharmaceutical and medical device companies to funnel millions of dollars a year, without disclosure, to doctors who teach continuing education programs. The conduits for the money are independent companies that sponsor medical lectures for doctors. Since 2011, drug industry payments to these outside companies have risen 25 percent, to $311 million in 2014. …”
“The biggest lobbying organization for doctors is fighting in Congress to keep those payments out of public view, backing a bill to derail an Obama administration push for more transparency. The lobbying group, the American Medical Association, says disclosure would unfairly stigmatize doctors who are leaders in their fields and deliver lectures on breakthroughs in medicine.”
The AMA Task Force to Reduce Opioid Abuse includes 27 physician organizations, including the APA, the AMA, the American Osteopathic Association, the American Dental Association and 17 specialty and seven state medical societies. Task force members will work to identify the “best practices” against opioid abuse.
Medscape reports that “An initial focus for the task force is to get physicians to register for and use state-based prescription drug monitoring programs (PDMPs), which can help in deciding whether to prescribe an opioid. ‘When used effectively, PDMPs can help assess your patient’s prescription history and immediately determine whether your patients have received prescriptions from other prescribers and dispensers, including those from other states,’ says the task force web page.
Modern Healthcare reports that for one year past the Oct. 1, 2015 deadline for adopting ICD-1o, the Centers for Medicare & Medicaid Services “will reimburse for wrongly coded claims as long as that erroneous code is in the same broad family as the right one. There had been concerns among providers that they wouldn’t be paid if they made minor mistakes trying to implement the new complex coding system.”
And so the American Medical Association, which has long criticized
the Obama administration’s order to move from ICD-9 to ICD-10 coding for diagnoses and inpatient hospital procedures, has decided to team with the CMS to make the transition easier for physicians.
