Here’s an update of data from Edward Salsberg, writing in HealthAffairs, on the pipeline of nurse practitioners, physician assistants and pharmacists needed to address America’s growing primary-care needs.
The Centers for Medicare and Medicaid Services wants to start a a Web site to better track enforcement actions against providers making dubious claims for reimbursement from Medicare.
The agency seeks a contractor to build and maintain the “Provider Compliance Reporting” system to be accessible on the future ProviderMedicare.gov site.
Consider such industry sectors as hospitals, physician groups, managed-care insurers, home health, drug manufacturers and devicemakers.
As Steven Ross Johnson writes in Modern Healthcare:
“One big reason the two programs powerfully seeded healthcare expansion is that political forces—ideologically and economically motivated—blocked the government from establishing effective cost controls. That meant taxpayers essentially wrote providers, insurers, suppliers and beneficiaries a blank check. This quieted initial opposition to the establishment of Medicare and Medicaid by making the programs profitable for private-market players. But the lack of cost controls, such as the global budgets used in other advanced countries, has created long-term financial headaches.”
Among the strategies: a wireless monitor under a mattress that alerts nurses to changes in breathing and heart rate. “Another approach rates a patient’s risk of serious deterioration in real time based on lab results, vital signs and nurses’ assessments gathered from electronic medical records.”
They are:
1. What’s the biggest barrier to practicing medicine today?
2. What is your most vivid memory involving a patient who could not afford to pay for healthcare (or meds, tests, etc.) and how did you respond?
3. What do you most often wish you could say to patients, but don’t?
4. If you could change or eliminate something about the healthcare system, what would it be?
5. What is the most important piece of advice for healthcare providers just starting out today?
6. What is your “elevator” pitch to persuade someone to pursue a career in medicine?
7. What is the most rewarding aspect of being a healthcare provider?
8. What is the most memorable research published since you became a physician and why?
9. Do you have a favorite medical-themed book, movie or TV show?
10. What is your advice to other physicians on how to avoid burnout?
This Medical Economics piece recommends, among other actions:
“Work with your practice management system, clearinghouse, or reporting mechanism to structure the denials into categories, aligning with the functions of your practice. Categorize denials related to coding (the diagnosis is inconsistent with the procedure) with your coder, eligibility issues (patient cannot be identified as our insured) with your front office, and pre-authorization (the authorization number is missing, invalid, or does not apply to the billed services or provider), and with the provider assigned to this task.”
P.J. Cloud-Moulds writes in Medical Economics:
“An article posted on BizJournal.com reports that the North Carolina Medical Society (NCMS), after 12 years of litigation, has finally won a lawsuit against United Healthcare for $11.5 million. I wholeheartedly applaud NCMS for sticking to their goals and not giving up, particularly after so many years! The lawsuit was not intended to make financial payments to providers, as much as it was to upgrade UHC’s provider self-service technology systems. Quite frankly, I’m not sure why they are not already required to maintain and upgrade their data platform, especially being a medical business entity of their size. Regardless, the lawsuit is over, and the little guys won.
“This is just one of many {such} lawsuits going on right now. …Patients are tired of being lied to by these insurance companies, and they’re supporting these lawsuits, as well. The lawsuits vary from allegedly violating anti-trust laws, to creating plans under the Affordable Care Act that do not have any physicians in their networks — forcing patients to pay more out-of-pocket expenses, and fighting wrongfully denied claims.
“Whatever the reasons, it’s clear that those being wronged by these large insurance payers are fighting back, and it’s about time.”
By MICHELLE ANDREWS, for Kaiser Health News
Actress Rita Wilson, who was diagnosed with breast cancer and underwent a double mastectomy recently, told People magazine last month that she expects to make a full recovery “because I caught this early, have excellent doctors and because I got a second opinion.”
When confronted with the diagnosis of a serious illness or confusing treatment options, everyone agrees that it can be useful to seek out another perspective. Even if the second physician agrees with the first one, knowing that can provide clarity and peace of mind.
A second set of eyes, however, may identify information that was missed or misinterpreted the first time. A study that reviewed existing published research found that 10 to 62 percent of second opinions resulted in major changes to diagnoses or recommended treatments.
Another study that examined nearly 6,800 second opinions provided by Best Doctors, a second-opinion service available as an employee benefit at some companies, found that more than 40 percent of second opinions resulted in diagnostic or treatment changes.
But here’s the rub: While it’s clear that second opinions can help individual patients make better medical decisions, there’s little hard data showing that second opinions lead to better health results overall.
“What we don’t know is the outcomes,” says Dr. Hardeep Singh, a patient safety researcher at the Michael E. DeBakey VA Medical Center and Baylor College of Medicine, in Houston, who co-authored both those studies. “What is the real diagnosis at the end? The first one or the second one? Or maybe both are wrong.”
That doesn’t mean second opinions are a bad idea. Experts estimate that diagnostic errors occur in 10 to 15 percent of cases.
“There’s no getting away from it, diagnosis is an imprecise thing,” says Dr. Mark Graber, a senior fellow at RTI International who also co-authored the studies. Graber is the founder and president of the Society to Improve Diagnosis in Medicine.
Second-opinion requests were related to diagnosis questions in 34.8 percent of cases in the Best Doctors study. These included 22.5 percent of patients whose symptoms hadn’t improved, 6.3 percent who hadn’t gotten a diagnosis and 6 percent who had questions about their diagnosis.
In Wilson’s case, she wrote that after two breast biopsies she was relieved to learn that the pathology analysis didn’t find any cancer. But on the advice of a friend, she decided to get a second opinion, and that pathologist diagnosed invasive lobular carcinoma. Wilson then got a third opinion that confirmed the second pathologist’s diagnosis.
Getting a second opinion may not involve a face-to-face meeting with a new specialist, but it will certainly involve a close examination of the patient’s medical record, including clinical notes, imaging, pathology and lab test results, and any procedures that have been performed. Some people choose to have that second look done by physicians in their community, but other patients look for help elsewhere.
In addition to employer-based services like Best Doctors or Grand Rounds, medical centers such as the Cleveland Clinic and Johns Hopkins in Baltimore also offer individual patients online second opinions.
“It really does give people relatively easy access to expertise,” says Dr. C. Martin Harris, chief information officer for the Cleveland Clinic.
The medical center’s MyConsult service doesn’t accept insurance. A medical second opinion costs $565, while a consultation with a pathology review costs $745.
Face-to-face meetings with specialists who provide a second opinion and review a patient’s medical record are more likely to be covered by insurance than an online consult, but nothing is guaranteed.
“Usually it’s not the second opinion where the hiccup is,” says Erin Singleton, chief of mission delivery at the Patient Advocate Foundation, which helps people with appeals related to second opinions. “It may be that the MRI that they want to do again won’t be approved.” Many insurers won’t pay for diagnostic or other tests to be redone, she notes.
Patients seeing an out-of-network specialist for a second opinion may encounter significantly higher out-of-pocket costs, particularly if they want to subsequently receive treatment from that provider. In those instances, the foundation can sometimes work with patients to make the case that no specialist in their network is equally experienced at treating their condition.
Of course, asking for a second opinion doesn’t necessarily mean accepting the advice. In the Best Doctors survey, 94.7 percent of patients said they were satisfied with their experience. But only 61.2 percent said they either agreed or strongly agreed that they would follow the recommendations that they received in the second opinion.
Much of it is motivated by the fear that the growing consolidation of physician groups and big hospital systems, such as Yale New Haven, is driving up prices.
Physicians are in a losing war to protect their turf as more more states (with Nebraska now the 20th) let nurses in a variety of medical fields practice without a doctor’s oversight, reports The New York Times. This change is especially attractive in rural states where physicians are often far, far away from patients.
So the nurses can order and interpret diagnostic tests, prescribe medications and administer treatments.
“The doctors are fighting a losing battle” against the nurses’ new powers, Uwe E. Reinhardt, a health economist at Princeton University, told The York Times. “The nurses are like insurgents. They are occasionally beaten back, but they’ll win in the long run. They have economics and common sense on their side.”
