CMS proposes edits of more than 10,000 CPT, HCPCS codes

In a move that could only be described as “unbelievable," the Centers for Medicare & Medicaid Services (CMS) has proposed edits of more than 10,000 CPT and HCPCS codes as part of its “medically unbelievable edits” program. In an effort to prevent the payment of erroneous Medicare claims, the program limits the units of certain services that can be provided per patient per day, such as services that would be anatomically incorrect (e.g., amputating three arms from one patient) or clinically unreasonable (e.g., installing more than one pacemaker). However, the validity of some of the edits are debatable, such as limits on the number of biopsies allowed per patient per day.

The AAFP and 91 other organizations have sent a letter to CMS to express their concerns about the time it will take them to review the edits and offer comments. The groups have proposed CMS use single review process, rather than a dual review process, and that it be extended to Sept. 15. They also have asked CMS to be more transparent about the rationale behind each edit.

The groups also urged CMS to establish modifiers for services that may be clinical outliers and to develop an appeals process.

Implementation is not anticipated until Jan. 1, 2007.

Small but growing numbers of physicians drop health plans

While it can hardly be described as an exodus, the percentage of U.S. physicians who do not participate with any managed care plans increased to 11.5 percent in 2004–2005, up from 9.2 percent in 2000–2001 and 8.6 percent in 1998–1999, according to a new report from the Center for Studying Health System Change. The report, No Exodus: Physicians and Managed Care Networks, is based on telephone interviews with more than 6,600 physicians.

The percentage of physicians without managed care contracts varied widely across communities, suggesting that local market conditions have a major influence on physicians' contracting decisions. The study also found that physicians without managed care contracts are more likely to practice in solo or two-physician practices, lack board certification in their specialty, work part time and have more than 20 years of experience as a physician.

Poor reimbursement rates and administrative hassles contribute to physicians' decisions to drop health plans. Researchers also noted that as more health plans loosen restrictions and pay a portion of patients' out-of-network care, it could become easier for physicians to drop their health plans but retain their patients. Researchers cautioned that this trend could lead to higher out-of-pocket costs for patients and a decline in access for patients who can't afford to pay more.

Colonoscopy guideline could aid FPs seeking privileges

A new guideline from the Residency Review Committee for Surgery of the Accreditation Council for Graduate Medical Education requires surgical residents to complete a minimum of 50 proctored colonoscopies before they can enter practice. While the requirement applies to surgical residents, it may help family physicians demonstrate their competency and obtain privileges. Using the guideline, those who have been proctored by a gastroenterologist or general surgeon and have performed the required number of colonoscopies could have an easier time making their case before a credentialing committee.

The guideline is viewable online at http://www.acgme.org/acWebsite/RRC_440/440_minReqLaparoscopy.asp.

United tests program to pay patients' share of medical bills

United Health Group launched a pilot program in April under which it will pay the patient's portion of a medical bill when a claim is processed and collect from the patient later. If the patient doesn't pay within 20 days, the insurer automatically deducts the amount due from a patient account, such as a flexible spending or health savings account. If one isn't available, the insurer deducts the amount, plus interest, from the patient's paycheck.

While the new program could save physicians and hospitals the hassle of collecting from patients, there is a catch: Providers must accept discounted reimbursement in exchange for guaranteed payment of the patient portion.

The program, called OnePay, is being piloted in Texas. Patient and provider enrollment is voluntary.

Who has the best job in America?

Physicians didn't make the top 10 in a recent ranking of the best jobs in America, but they did make the top 30. The rankings are based on job growth, average pay, stress levels, flexibility in hours and working environment, creativity, and how easy it is to enter and advance in the field.

Physician assistants had the highest job growth in the survey, while physicians/surgeons had one of the highest salaries, second only to chief executive officers. Note that the average pay listed for physicians/surgeons was $247,536. According to AAFP data, the average family physician makes $143,600.

"Steep decline" in competition benefits health insurers

Health insurance companies are seeing a “steep decline” in competition in their markets, according to a new report from the AMA.

“The remarkable reduction in the number of competing health plans is troubling for doctors and patients, as competition drives innovation and efficiency in the health care system,” said AMA board member J. James Rohack, MD.

Titled Competition in Health Insurance: A Comprehensive Study of U.S. Markets, the study found that in 95 percent of markets, a single insurer held a 30-percent or greater market share. In 56 percent of markets, a single insurer held a 50-percent or greater market share.

Massive mergers over the last decade have contributed to the lack of competition. However, “patients do not appear to be benefiting from the consolidation of health insurance markets,” said Rohack. “Health insurers are posting historically high profit margins, yet patient health insurance premiums continue to rise without an expansion of benefits.”

Rohack called on federal regulators to examine whether patients are being harmed because of the lack of competition.

Researchers examine what makes a small medical group exemplary

Noting that small groups provide 90 percent of medical care in the United States, researchers recently examined what makes a small group successful. The study, “Transforming Medical Care: Case Study of an Exemplary, Small Medical Group,” published in the March–April issue of Annals of Family Medicine (http://www.annfammed.org), focused on a 15-family-physician group selected based on its high public performance scores.

The analysis identified 12 attributes that contribute to the group's success:

1. Strong leadership. While the group uses an informal consensus process for making most day-to-day decisions, two physician managers share operational decision making. Leadership is strong, consistent, top-down and bottom-up, with an emphasis on leading by example and encouragement.

2. Patient-centeredness. All systems are built around patients' needs. For example, to ensure that patients seeing more than one physician in the group receive consistent advice, the group follows a standardized approach to care.

3. Primacy of the physician-patient relationship. The group aims to make the doctor-patient interaction as efficient and effective as possible. For example, the group follows an extremely organized paper charting system that includes a “chart-prepper,” whose sole duty is to prepare the chart for each scheduled visit so the physician has the information he or she needs.

4. A sense of ownership and responsibility among physicians. Physicians in the group feel responsible for both clinical and administrative aspects of the practice, and they act as champions for new initiatives.

5. Involvement and engagement of all staff. All physicians and staff understand the group's mission, vision, values and strategies, and they are involved in any change that affects their work.

6. Highly organized change management. Committees oversee all aspects of the practice, from laboratory to forms to safety, and they meet regularly for planning and maintenance. Any change involves pilot testing and measurement.

7. Focus. The group avoids trying to improve too many things at once. The group's leaders and physicians are selective about which initiatives to pursue, concentrating on changes that will have the most positive impact on patients.

8. A culture of improvement. At all levels, the group's employees understand that change and continuous improvement are necessary. They feel invigorated by change rather than threatened by it because they know they will be able to influence the changes.

9. Teamwork and standardization. To foster teamwork among physicians, the group offers equal pay, carefully selects new clinicians and provides them with mentors and extended orientation. It also establishes performance standards.

10. Attention to market concerns. The group realizes that to survive and thrive as an independent group, it needs a distinguishing feature to attract patients. That feature is quality.

11. Data, transparency and accountability. The group uses measurement to assess whether a change is successful and whether individuals are performing at the required level. The results are often posted internally.

12. Pride and joy. Physicians and staff have a high sense of job satisfaction and feel proud of what they are accomplishing.

Researchers admitted that the study does not provide definitive answers but does raise hypotheses that may help the physician community better understand what differentiates successful organizations from those that are not successful.