Archives for 2011

How Should Wisconsin Address Its Worsening Physician Shortage?

According to the Wisconsin Hospital Association (WHA), by the year 2030, the state will face a shortfall of at least 2,000 physicians, particularly primary care practitioners and those practicing in rural areas and inner-city Milwaukee. The WHA places part of the blame on federal health care reform initiatives, which will increase the number of insured persons, nationally, by an estimated 30 million people. An additional culprit is the state’s reliance on recruiting physicians from other states due to the failure to retain medical school graduates from the state’s two medical schools. Considering the rapidly aging population of Wisconsin, the resulting number of retiring physicians, and the growing number of insured persons, the WHA concludes that the state must produce at least 100 new physicians per year, in addition to the number currently produced, in order to meet the increasing demand.

Since federal health reform and the aging population will increase the demand for physicians in all states, Wisconsin will find it more difficult to rely on the recruitment of physicians from other states. The two Wisconsin medical schools currently graduate 340 new doctors per year; however, only 38 percent of those graduates remain in Wisconsin to practice medicine. Consequently, the state has been recruiting approximately 720 physicians per year from out-of-state.

The WHA maintains that the best solution to retain medical school graduates is to increase the number of “home-grown” physicians from Wisconsin. The state in which a graduate completes his or her residency is a strong predictor of where that doctor will ultimately practice, with 70 percent of in-state medical students who complete their residencies in Wisconsin electing to practice in Wisconsin. The WHA is currently investigating ways to increase the number of residency spots in the state, as well as the capacity of medical schools.

Major roadblocks to increasing residency positions have been state budget cuts affecting residency funding and a cap on the amount Medicare will contribute to funding such positions. Some residency spots have been entirely funded by the hospitals themselves, which are struggling with their own budgets. According to George Quinn, the senior policy advisor of WHA, a collaborative approach is necessary among various “stakeholders,” including providers, hospitals, communities and the state’s medical schools, in order to find a funding solution.

While both state medical schools have made attempts to increase enrollment, some advocate that a third medical school is necessary to produce the additional 100 graduates per year, particularly those who will practice in rural areas. Aspirus Health System, located in rural Wisconsin, is investigating the development of a new medical school in northern Wisconsin. If the results of a feasibility study, due in February 2012, are positive and Aspirus can attain enough financial support, it hopes to enroll 100 students per year with the first class graduating in 2017.

Other solutions suggested include the forgiveness of medical education debt for graduates who choose to practice in Wisconsin and a movement toward a multi-disciplinary team approach to health care delivery. One thing is for certain: action taken to address the shortage must be swift. Any time wasted will only deepen the crisis.


Reducing Hospital Readmissions: Follow-up Care is Key

Although the quality of care during an inpatient hospital stay has been the focus of readmissions, a significant reason for readmissions may be because patients have obtained or did not receive appropriate follow-up care and outpatient management after a hospitalization. Reasons for patients’ lack of post discharge care include lack health insurance or a primary care physician, inability to get an appointment with the primary care physician in a reasonable amount of time, not being able to afford medication, and poor diet or not following a diet.

The Medicare program has targeted quality of care issues in hospitals for many years, requiring hospitals to report on quality of care or be penalized by reducing the amount of payment the hospital receives. Under §3025 of the Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148),  (see Social Security Act §1886(q)), Medicare will begin imposing financial penalties on acute care hospitals that have excess risk-adjusted rates of readmission for heart attack, heart failure, and pneumonia during fiscal years beginning on or after October 1, 2012. Hospitals most likely to be impacted by the penalties would be those hospitals with the largest share of poor patients, according to Kaiser Health News (KHN) analysis of data CMS collected and reported on the Medicare Hospital Compare Website. KHN concluded that hospitals treating poorer patients were 2.7 times more likely to have high readmission rates.

 Although the emphasis has been on payments made by Medicare for readmissions, it should be noted that private insurers pay a greater share of 30 day readmissions (47%) than Medicare does (40%), according to authors Anna Sommers, Ph.D., HSC Senior Researcher, and Peter J. Cunningham, Ph.D., HSC Director of Quantitative Research, in their article, Physician Visits after Hospital Discharge: Implications for Reducing Readmissions, in the December issue of the Research Brief, a publication of the National Institute for Health Care Reform.  In addition, Sommers and Cunningham stressed that reforms specific to one payer [i.e. Medicare] that focus only on hospital care may fall short unless attention is given to efforts to coordinate with community providers and encourage patients to access to these providers.

“Understanding what care patients receive after discharge is critical to designing effective policies that support provider efforts to reduce avoidable readmissions,” Sommers and Cunningham stated. The authors identified strategies that could address gaps in care after discharge including bundled payments and patient-centered medical home efforts, which could potentially encourage hospitals and community-based clinicians to work together to lower rates of avoidable readmissions or rehospitalizations for other conditions.  In addition, they explained how health information technology could help physicians identify and monitor care for high-risk patients and foster information sharing between hospitals and community-based physicians.

The KHN analysis stated that a key reason for so many readmissions is that one third of adult patient discharged from a hospital do not see a physician within 30 days of discharge. To interrupt this pattern, KHN reported that some hospitals are turning to post-discharge clinics and identifying patients who are more likely to have trouble after discharge because of their medical conditions or because they lack health insurance or a primary care physician.

CMS also has recognized the need for post-discharge care. PPACA §3026 requires the establishment of a Community-Based Care Transitions Program to provide funding to “eligible entities” that furnish improved care transition services to high-risk Medicare beneficiaries. “Eligible entities” means a hospital identified as having a high readmission rate or an appropriate community-based organization that provides care transition services across a continuum of care. The Community Based Care Transitions Program  goals are to reduce hospital readmissions, test sustainable funding streams for care transition services, maintain or improve quality of care, and document measurable savings to the Medicare program

Reducing hospital readmissions will reduce costs, hopefully, as the result of improved quality of care. Improved quality of care should include hospital care as well as post-discharge care. To attain improved quality of care, post-discharge care should be a coordinated effort between hospitals, community providers, and patients.

DOJ Boasts $2.4 Billion Recovered from Health Care-Related Fraud Cases in 2011

The Department of Justice announced last Monday that of the more than $3 billion recovered under the False Claims Act in 2011, $2.4 billion stemmed from recoveries from fraud against federal health care programs.   Included in those programs that were the target of fraud were Medicare, Medicaid, TRICARE, Federal Employees Health Benefits, and Veterans Administration health programs.

According to Assistant Attorney General for the Civil Division, Tony West, since the False Claims Act was amended in 1986, $30 billion dollars have been recovered, and “[28] percent of the recoveries in the last 25 years were obtained since President Obama took office [in 2009].”  The new release states that fighting health care fraud is a top priority for the Obama Administration, and credits the Health Care Fraud Prevention and Enforcement Action Team (HEAT), created in May 2009, for much of the DOJ’s success.  

It does not appear to be coincidence that the False Claims Act recoveries have so drastically increased since Obama took office.  HEAT’s mission, according to the team’s website include:

  • (1) utilizing government resources to prevent waste, fraud, and abuse in Medicare and Medicaid;
  • (2) reduce health care costs and improve quality of care;
  • (3) highlight best practices by providers and public sector employees; and 
  • (4) add to DOJ and HHS relationships, like Medicare Fraud Strike Forces, to reduce fraud and recover taxpayer dollars. 

The Obama Administration also plans to invest funds in strengthening program integrity in Medicare and Medicaid, particularly with regard to Medicare Advantage and Medicare prescription drug programs.  [For more information on HEAT, refer to the program’s website.]

Also credited for the large recovery is the passage of the Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148) last year, which provided more incentive for whistleblowers to step forward and strengthened the Anti-Kickback Statute. 

The pharmaceutical industry was the biggest source of recoveries, according to the DOJ news release, with nearly $2.2 billion coming from civil claims, including $900 million from eight drug manufacturers for engaging in illegal pricing, and $750 million from civil and criminal claims against GlaxoSmithKline PLC for knowingly submitting, or causing to be submitted, false claims for adulterated drugs and for drugs that did not meet the strength, purity or quality required by the Food and Drug Administration.

A record amount of $2.8 billion came stemmed from whistleblower provisions of the False Claims Act which allow private citizens to bring suit (qui tam suits) on behalf of the federal government.  A total of 638 qui tam actions were filed over the past year.

Physician Payments, Other Expiring Medicare Statutes, Extended for Two Months

Physicians will be paid at existing levels for services provided under Medicare at least until the end of February 2012 under legislation passed by Congress on Dec. 23 and signed into law by President Obama the same day. 

Without action by Congress, physicians faced a 27 percent reduction in Medicare payments on January 1, 2012. Under the new law, Medicare physician payments will be maintained at current levels until February 29, 2012. 

The “Temporary Payroll Tax Cut Continuation Act of 2011” (HR 3765) also keeps the payroll tax at the current 4.2-percent rate instead of reverting to 6.2-percent. The legislation includes some of the provisions previously commented on in this post.  

The legislation also extends for two months—until February 29, 2012—several other Medicare statutes that were set to expire on December 31, 2011, including –

  • the 1.0 floor in the work geographic index under the inpatient hospital prospective payment system for any locality for which the index is less than 1.0;
  • exceptions to the payment cap for services provided by physical and occupational therapists, and speech-language pathologists;
  • payment for the technical component of certain physician pathology services;
  • a temporary payment increase for rural ambulance providers;
  • the physician fee schedule mental health add-on payment;
  • the outpatient hold harmless provision for small rural hospitals;
  • the minimum payment for bone mass measurement;
  • the “qualifying individual” program under Medicaid; and
  • Transitional Medical Assistance under Medicaid 

In addition, the deadline for geographic reclassification of hospitals was extended from September 30, 2011, until November 30, 2011, for consideration for fiscal year 2012 reimbursement under the inpatient hospital prospective payment system.