CMS Proposes Changes to Physician Fee Schedule

CMS Proposes Changes to Physician Fee Schedule, from ACEP / EM Today

Last week, the Centers for Medicare & Medicaid Services (CMS) issued a notice of proposed rule making that concerns changes to the Medicare Physician Fee Schedule for 2007, including a revision of physician work Relative Value Units (RVUs) that could mean an increase in emergency physician reimbursement for providing Evaluation and Management (E/M) services.

Although the values published in the proposed rule will not be final until the comment period ends and the final rule for the 2007 Medicare Fee Schedule is published in late fall, work RVUs for emergency department E/M codes should have significant increases. The actual financial impact for each member will depend on several factors such as patient volume, payer mix, service mix, and frequency distribution. The combination of these factors can have a significant impact on the total annual Medicare payment in the ED.

Family Presence in ED Resuscitations

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Hospitals are allowing loved ones into the ER, even when the going gets rough. CNN's Tom Foreman reports.

Doctors' Average Pay Fell 7% in 8 Years, Report Says

From the NY Times, via Symtym:

The Dr. Smiths are having trouble keeping up with the Mr. Joneses.

A report planned for release today indicates that the average physician's net income declined 7 percent from 1995 to 2003, after adjusting for inflation, while incomes of lawyers and other professionals rose by 7 percent during the period.

The researchers who prepared the report say the decline in doctors' inflation-adjusted incomes appears to be affecting the types of medicine they choose to practice and the way they practice it — resulting in fewer primary care doctors and a tendency to order more revenue-generating diagnostic tests and procedures.

Primary care doctors, who are already among the lowest-paid physicians, had the steepest decline in their inflation-adjusted earnings — a 10 percent drop — according to the report by the Center for Studying Health System Change, a nonprofit research group in Washington.

The average reported net income for a primary care physician in 2003 was $146,405, according to the study, after expenses like malpractice insurance but before taxes. The highest-paid doctors were surgeons who specialize in areas like orthopedics, who had an average net income of $271,652, nearly double what the primary care doctors said they earned.

The report was based on a national telephone survey of roughly 6,600 physicians in 2004 and 2005 and earlier surveys by the research center. "These are large enough changes that physicians are responding," said Paul B. Ginsburg, the center's president and a health economist.

Doctors, he said, are reacting to the financial incentives under the current payment system by choosing to specialize and work in fields where they can increase their income by providing more services, like diagnostic tests or procedures, he said.

Dr. Cecil B. Wilson, the chairman of the board of the American Medical Association, said that for practicing physicians the survey "confirms what they already know from their own practices: payments are not keeping up with inflation.

Physicians barred from using cursive to write prescriptions

From the Seattle Post-Intelligencer, via Symtym:

Physicians, heal thy handwriting.

On June 7, a new law went into effect that could paralyze the penmanship-impaired. It says that if a prescription isn't hand-printed, typed or electronically generated, it can't be filled, Jeff Smith of the state Health Department explained.

Cursive is illegal.

Dr. Richard Goss, medical director of quality improvement at Harborview Medical Center, said he is in favor of the bill because his own handwriting is hard to read.

"One of the comic strips on my office wall is a physician's guide to the alphabet," he said. "Each letter is illegible."

Goss said his handwriting probably was readable when he was in junior high, but it went downhill from there. Years of fast handwriting and note-taking took their toll.

As a result, he's been forced to slow down when he writes prescriptions, print carefully, read them over and make sure someone else can read them. He also double-checks figures.

If physicians, veterinarians and other prescription writers want to assign blame for this bill, Dr. William Robertson of the Washington Poison Center is willing to accept it.

Robertson said it's taken him 27 years to make scrawled prescriptions illegal. Lots of doctors are opposed to this, but it will save drug errors, he said.

Increased CMS Payments for Emergency Medicine

From ACEP:

American College of Emergency Physicians is proud to announce that the Centers for Medicare and Medicaid Services will increase payments for emergency medicine Evaluation and Management codes beginning in January 2007.

According to a proposed notice released by CMS this week, the Relative Value Units for emergency medicine E/M codes will increase from 8.1% to 60%, or about 25% across the board. The actual financial impact for each ACEP member will depend on several factors, including patient volume, payer mix, and frequency distribution.

You can calculate the impact these increases will have on your payments by going to www.ACEP.org. We have created an interactive calculator that will allow you to see what you can expect to be reimbursed in 2007.

US hospitals sued in class action over nurse pay

From Reuters:

Nurses backed by the biggest U.S. health-care union on Tuesday filed four class-action lawsuits against some of the biggest U.S. hospitals, including No. 1 chain HCA Inc., claiming they conspired to depress wages for nurses amid a national shortage.

The lawsuits, which also target the biggest U.S. Catholic hospital system, Ascension Health, charge the hospitals regularly discussed nurses' wages in meetings, over the telephone and in written surveys, in an effort to coordinate and suppress pay.

The suits, filed in federal courts in Chicago; Memphis, Tennessee; Albany, New York; and San Antonio, Texas, seek back compensation and legal costs totaling "hundreds of millions of dollars" under federal antitrust laws.

Reasons for Being Admitted to the Hospital through the Emergency Department, 2003

More HCUP Highlights, from Statistical Briefing #2

Circulatory disorders (diseases of the heart and blood vessels) were the most frequent reason for admission to the hospital through the ED, accounting for 26.3 percent of all such admissions; injuries accounted for 11.4 percent.

The top 20 specific conditions accounted for more than half of all hospital admissions through the ED, with pneumonia as the single most common specific condition at nearly one million (5.7 percent) of all such admissions.

Complications of procedures, devices, implants, and grafts ranked as the ninth most common reason for admission through the ED and included postoperative infections, malfunction of orthopedic devices, and infection of arteriovenous fistulas used for dialysis.

The top 20 specific conditions admitted through the ED included several chronic conditions: chronic obstructive lung disease, asthma, diabetes, and mood disorders. Also included were fluid and electrolyte disorders; urinary, skin, and blood infections; gall bladder disease, gastrointestinal bleeding, and appendicitis; and hip fracture.

While up to 82 percent of the most frequent acute conditions were admitted through the ED, a large percentage of chronic conditions were also admitted through the ED; for example, 72 percent of cases with conestive heart failure, chronic obstructive lung disease, and asthma were such admissions.

Highlights: Hospital Admissions That Began in the Emergency Department, 2003

From the HCUP project website, Statistical Brief #1

In 2003, 55 percent of 29.3 million hospitalizations (excluding pregnancy and childbirth) began in the ED.

Relative to the populations in each region, individuals in the Northeast were more likely to enter the hospital through the ED, while individuals in the Western states were less likely.

Government payers, Medicare and Medicaid, bear the greatest burden of hospital admissions through the ED, covering 66 percent of all admissions through the ED.

The mean cost for hospitalizations that began in the ED was $7,400.

The mean costs for hospitalizations that began in the ED were highest in the West ($8,500) compared to all other regions of the country ($7,200 or less).

The mean costs for hospitalizations that began in the ED were greatest for government payers.

The mean cost for uninsured stays that began in the ED was less than the cost of stays billed to Medicare and Medicaid but comparable to stays billed to private insurance.

Institute of Medicine Report on Hospital-Based Emergency Medicine

From the IOM website:

Despite the lifesaving feats performed every day by emergency departments and ambulance services, the nation's emergency medical system as a whole is overburdened, underfunded, and highly fragmented, says this series of three reports from the Institute of Medicine.

As a result, ambulances are turned away from emergency departments once every minute on average and patients in many areas may wait hours or even days for a hospital bed. Moreover, the system is ill-prepared to handle surges from disasters such as hurricanes, terrorist attacks, or disease outbreaks.

The Institute of Medicine's Committee on the Future of Emergency Care in the United States Health System was convened in 2003 to examine the state of emergency care in the U.S., to create a vision for the future of emergency care, including trauma care, and to make recommendations to help the nation achieve that vision. Their findings and recommendations are presented in three reports:

Hospital-Based Emergency Care: At the Breaking Point explores the changing role of the hospital emergency department and describes the national epidemic of overcrowded emergency departments and trauma centers.
Emergency Medical Services At the Crossroads describes the development of EMS systems over the last forty years and the fragmented system that exists today.
Emergency Care for Children: Growing Pains describes the unique challenges of emergency care for children.
The wide range of issues covered in this report, Hospital-Based Emergency Care: At the Breaking Point, includes:

The role and impact of the emergency department within the larger hospital and health care system.
Patient flow and information technology.
Workforce issues across multiple disciplines.
Patient safety and the quality and efficiency of emergency care services.
Basic, clinical, and health services research relevant to emergency care.
Special challenges of emergency care in rural settings.

Hospital drug ads make some critics feel ill

From The Gazette (Montreal):

It's safe to assume that most people don't have sex on the brain in a hospital emergency room.

That might explain why the Viagra ad in the ER area at the Montreal General Hospital once caused a bit of a fuss.

"It wasn't the ad itself," said Francoise Chagnon, director of professional services at the McGill University Health Centre.

But doctors felt it didn't belong in a clinical area. "When you looked at the big ad, it kind of stood out right when you came to register in the emergency room and that wasn't appropriate," Chagnon said.

That incident aside, Chagnon said commercial advertising in the hospital hasn't sparked complaints. But the revenue-generating practice isn't without critics.

In the late 1990s, the Montreal General began accepting commercial advertising as a way to drum up new revenue. Some other cash-strapped hospitals are doing the same thing. However, even among hospitals there is no consensus on the practice.

"This is not the way we should be raising money," said Paul Saba, a spokesperson for the Coalition of Physicians for Social Justice.

Lawsuit won over doctor's undisclosed drug problem

From the Seattle Times, via Symtym:

Washington hospital and a malpractice insurer have successfully sued a Louisiana hospital and two doctors who wrote glowing letters of recommendation for a colleague without disclosing his drug problem.

The jury award of more than $4 million for fraud and negligent misrepresentation marks the first time one hospital has successfully sued another for failing to disclose adverse information about a doctor being considered for privileges to practice there, liability experts said.

The case was brought by Seattle-based Western Professional Insurance and Kadlec Medical Center, the Richland hospital that later hired Dr. Robert Lee Berry, unaware of his history.

In 2002, one of Berry's patients, Kim Jones of Richland, then a 31-year-old mother of three, sustained severe brain damage during a routine procedure. Jones is in a nursing home in Michigan unable to care for herself.

Two years later, Berry, an anesthesiologist, and Kadlec agreed to an $8.5 million settlement in a lawsuit brought by Jones' family.

During that lawsuit, Jones' family learned that Berry had been diverting the narcotic painkiller Demerol from his patients. They also learned he had been asked to leave the Louisiana hospital and his practice for being impaired on the job — a fact neither had disclosed to Kadlec.

"Had we known, we wouldn't have hired him," Kadlec spokesman Jim Hall said.

Ron Perey, Jones' lawyer, said "a case like this has never been won before." He predicted it would bring about positive changes in "honesty in the medical industry."

Med Tech Firms Move Standards Forward

From the Iowa Hospital Association "What's New" Section:

Twenty-two electronics and health companies announced a joint effort to help patients by making high-technology tools work better together. Participants said they were responding to an impending crisis, as a fixed number of doctors and nurses will confront an expected explosion in chronic diseases.

The companies are forming a nonprofit organization, called the Continua Health Alliance, with initial members that include Intel Corp., International Business Machines Corp., Cisco Systems Inc., Samsung Electronics Co., Motorola Inc., Philips Electronics NV, Medtronic Inc., General Electric Co.'s GE Healthcare unit, Kaiser Permanente and Partners HealthCare System Inc., among others. Additional companies are expected to join.

Continua backers expect to shift more care to the home, using devices that monitor the condition of patients and transmit data to medical professionals for analysis and recommendations. Besides helping patients help themselves, the companies hope to make it easier for family members to remotely monitor the condition of patients.

Standard-setting bodies already have been formed to address some of those issues. Continua hopes to go a step further, publishing guidelines so manufacturers can be assured that products they make will work with those from other firms.

ACEP CME: Chest Pain

A new continuing education activity from the American College of Emergency Physicians (ACEP): Focus on Chest Pain.

We all know what to do for the patient whose pain is described as a crushing pressure in the middle of his chest radiating to his left arm, associated with diaphoresis and shortness of breath. However, many patients present with a hodgepodge of "atypical features" that require the emergency physician to balance high-risk and low-risk features. And what about other life threats? Aortic dissection and pulmonary embolism are two notoriously tricky diseases that may present in a variety of ways.

While it has been consistently shown that history alone cannot rule out these life threats altogether,1-4 it does allow an emergency physician to determine the optimal plan of treatment and disposition. To do this well, the emergency physician must know which features indicate higher risk and not be lulled into a false sense of security by one reassuring feature. This article will highlight the most important features of the patient history for chest pain from recent literature.

Disaster Medicine Resources

From Medgadget:

NYU Hospital's Center for Health Information Preparedness (CHIP) has put their disaster medicine curriculum online -- including downloadable PDA content and patient resources.

The curriculum is thorough, covering the major threats from infections and toxins, how to spot them and treat them. References, too.

Cricothyroidotomy keychain

From Medgadget:

Have you ever been on a street, in a building, and just wanted to intubate someone, but didn't have the right equipment? Well, no need to haul around a heavy airway kit anymore -- just take LifeStat -- now you can perform cricothyroidotomy with your keychain:

LifeStat is an emergency airway device for use in respiratory obstruction or failure. This innovative device facilitates a lifesaving method (cricothyroid notch) in emergencies when other efforts have failed. LifeStat is small and light enough to fit on your key ring, in your pocket, or in your emergency kit.

Etomidate Versus Midazolam for Out-of-Hospital Intubation: A Prospective, Randomized Trial

A study published in the Annals of Emergency Medicine:

The primary objective of this study is to compare the intubation success rates of etomidate and midazolam when used for sedative-facilitated intubation, without paralytics, in out-of-hospital adult patients.

One hundred ten patients were enrolled in the study; 55 patients received midazolam and 55 patients received etomidate. The 2 groups were similar with regard to age, sex, initial vital signs, and reasons for intubation or sedation. The overall intubation success rate was 76% (95% confidence interval [CI] 68% to 84%); 75% (41/55) for midazolam (95% CI 64% to 86%) and 76% (42/55) for etomidate (95% CI 65% to 87%). There was also no difference in incidence of hypotension, number of intubation attempts, or perceived difficulty of intubation. Additional sedation was requested almost equally for the 2 groups: 14 patients in the midazolam group and 12 patients in the etomidate group. A benzodiazepine was successful for rescue of a failed etomidate intubation 10 of 12 times (83%; 95% CI 62% to 100%). When used for rescue of failed midazolam intubations, benzodiazepines were effective in only 5 of 14 (36%, 95% CI 11% to 61%) attempts.

Press Ganey LOS Study, Part 2

From the Des Moines Register:

Hospital patients in Iowa spend less time in emergency departments than patients in any other state — and more than 2 1/2 hours less than patients in Arizona, a report shows.

State and national health officials cite several factors for Iowa's top rating, pointing out that many of the state's 117 hospitals are in less-populated rural areas, and that the state's hospital occupancy rates are lower than the national average.

Iowans spend an average of two hours and 18 minutes in hospital emergency rooms, compared with the national average of three hours and 42 minutes, the report says. In Arizona, which ranked last, patients spend an average of almost five hours in the emergency department.

But the report's findings are important to Iowans for more than promotional reasons, experts say. Studies have shown that patient satisfaction is tied directly to how long people spend in the emergency room. And the more efficient an emergency department is, the fewer the mistakes.

"You want people to go where they're supposed to go in the most efficient manner possible," said Glenn Hamilton of Wright State University in Dayton, Ohio, who is past president of the Society of Academic Emergency Medicine. "It's not just a satisfaction issue. It's a safety issue."

Press Ganey Length of Stay Study

From USA Today, via Symtym:

Hospital patients in Arizona spend more than twice as much time in the emergency department as those in Iowa and Nebraska, a report shows.

But wherever you live, you might want to bring something to read. The average length of stay in U.S. emergency rooms is 3.7 hours, or 222 minutes. The state-by-state look at emergency department waiting times was conducted by Press Ganey Associates, which measures patient satisfaction for 35% of the nation's hospitals.

The report on emergency-room times is based on about 1.5 million patient questionnaires filled out in 2005. And it shows wide state-to-state variations in the time between entering the hospital's emergency department and being admitted or sent home. (Idaho is not included because there wasn't enough data available.)

Iowa (138.3 minutes) and Nebraska (146.1 minutes) had the shortest emergency-room stays, while Maryland (246.9 minutes), and Arizona (297.3 minutes) had the longest.

The findings are important because studies have shown that the less time patients wait to be seen, or spend in the emergency room, the greater their satisfaction with their care. As emergency-room visits continue to increase, many hospitals are promising to see patients quickly as a marketing tool.