Executive order calls for transparency and information technology in medicine

All federal agencies and their contractors that administer or sponsor a federal health care program must make information about the quality and price of health care available to their beneficiaries, enrollees and providers, according to an executive order signed by President Bush on Aug. 22. The executive order also requires that the agencies use interoperable health information technology and standard quality measures as well as develop and identify practices to promote high-quality care.

The four specific agencies affected oversee almost a quarter of Americans covered by health insurance: Health and Human Services oversees Medicare, the Department of Defense oversees TRICARE for the military, and the Department of Veterans Affairs and the U.S. Office of Personnel Management both oversee the Federal Employees Health Benefit Program. In a panel discussion before signing the order, President Bush explained that the federal government spends a lot of money within Medicaid and Medicare, veterans’ benefits and Department of Defense.

“And one of the initiatives [Health and Human Services Secretary] Mike [Leavitt] is now going to undertake is, say, in order to do business with the federal government, you’ve got to show us your prices, and you’ve got to help us develop a qualitative standard so the people that we’re trying to help know what they’re getting,” Bush said.

The goal of these initiatives is to make cost of care and quality transparent — using market strategies that dictate success for well-made, well-priced products — so that ultimately costs for health care drop and quality rises. The agencies have until Jan. 1, 2007 to comply with the new measures.

The concept of health transparency empowering consumers to shop around for bargain health care to lower prices and improve quality is key in the Bush administration’s health care policy. One component the administration supports is the expansion of health savings accounts for patients. HSAs are high-deductible tax-free savings accounts in which an individual invests to cover medical costs. That means that a large chunk of initial costs comes directly from the patient’s pocketbook until costs reach a catastrophic level and the insurance company steps in. Bush is counting on the relationship between thrifty Americans and their wallets to inspire cost-conscious spending.

A fact sheet from the White House supports giving consumers information about their health options, the quality of doctors and hospitals in their areas and the cost of procedures, to help them make informed health care decisions. This information will come from a variety of potential sources, the fact sheet reports, including insurance companies, employers, and Medicare-sponsored Web sites. However, a recent report from the Chicago Tribune found that health transparency has been largely impeded by private health insurance companies unwilling to release specific claims information, physicians who cannot accurately report health plan reimbursement and the government not reporting prices or quality under the terms of contract confidentiality.

For physicians who care for beneficiaries of federal health care programs, it is unclear how mandated transparency and interoperability will affect their practices.

A press release from HHS states that the executive order should help support doctors and hospitals in providing high-quality care and avoiding excess health care costs, but doesn’t give specific reporting methods.

“Basically, if [providers] want to participate in the federal programs, they will have to comply with the new provisions — interoperability and transparency,” says Doreen Bell, an AAFP government relations representative. “They’ll have to start thinking about how to disclose this information, which is going to be more complicated.”

While the executive order is only binding for the four federal programs, the Bush Administration hopes that those in the private sector will see this collaboration of agencies as a positive demonstration project and adopt some of these measures to improve health care overall. Bush supports this teamwork, explaining that the order “basically commits the federal government to work with state and local docs and hospitals to lead the way and be a part of this new movement about transparency in pricing and quality.”

---

Primary care income down 10 percent

Average physician income dropped more than 7 percent between 1995 and 2003 after adjusting for inflation, according to a national study from the Center for Studying Health System Change. The decline in income stands in sharp contrast to the income of professional or technical workers who saw an increase of about 7 percent. Primary care providers took the biggest hit with an income drop of more than 10 percent over this period. The second largest drop, 8.2 percent, hit surgical specialists, though average income for this group still stands at about $272,000 or 86 percent higher than the average pay of primary care physicians.

Overall work hours for all specialties has decreased, but time spent in direct patient care has increased. Spending the majority of work time on non-reimbursable patient education and administrative duties, such as face-to-face contact with patients, patient record-keeping and office work, travel time connected with seeing patients and communication with other health care providers, means lower income.

The study attributes physician income decline mostly to the flat or declining fees from private and public payers. The authors project that statistics like these cause growing physician unwillingness to contribute charity care or volunteer for hospital committees as well as a bleak outlook for primary care as more students choose the set hours and dependable income of other specialties.

Read the study, “Losing Ground: Physician Income 1995-2003,” on the Center for Studying Health System Change Web site, www.hschange.org, for more information.

---

TAFP speaks out on Medicare payment, scope of practice and HIT

TAFP has been working hard to represent the interests of family medicine and increase awareness of the importance of primary care. In the past couple of months, TAFP staff and leadership have spoken out through letters and testimony to key national policymakers on issues such as Medicare and Medicaid changes, several health information technology issues and family physicians’ roles in performing electrodiagnostic studies.

In letters to CMS Administrator Mark McClellan, M.D., Ph.D., and Trailblazer Health Enterprises Director Charles Haley, M.D., TAFP addressed upcoming Medicare payment changes. To CMS, the Academy expressed its support of recommendations made by the American Medical Association’s Relative Value Scale Update Committee (RUC) to increase the work value of evaluation and management services, but expressed concern for budget neutrality adjustments that foreshadow deep cuts in reimbursement rates to family physicians. To Trailblazer Health Enterprises, the Academy commented on a draft Medicare local coverage determination that restricts family physicians’ abilities to perform electrodiagnostic studies. Another letter to Texas Medical Association President Ladon Homer, M.D., encouraged TMA to support the Academy in advocating these issues.

TAFP’s testimony to the Senate Committee on State Affairs outlined how primary care can lead the effort to contain rising health care costs through implementing health information technology and universal transparency measures. A letter to U.S. Sen. Kay Bailey Hutchison expressed advice on a logical timeline for replacing the International Classification of Diseases, 9th edition, Clinical Modification (ICD-9-CM) diagnosis and procedure billing codes with the new ICD-10-CM/PCS codes.

TAFP will continue to educate the public through these advocacy efforts and others to come. Check out these and other TAFP advocacy activities on the TAFP news page at www.tafp.org.

---

HHSC launches Medicaid resource Web page

The Health and Human Services Commission’s Office of Community Collaboration has launched a Web page that brings Medicaid informational resources together and acts as an interactive forum. Providers can e-mail the OCC at occ@hhsc.state.tx.us with questions or to share their best practice tips, all of which will be used to improve the delivery of Medicaid.

The launch’s announcement appeared in HHSC’s July/August edition of the e-newsletter, In Touch.

To view the new Web page, go to www.hhsc.state.tx.us/medicaid/OCC.

---

PCCM withdrawal initiated

Starting Dec. 1, State of Texas Access Reform Medicaid patients, except SSI-related clients, living in the certain urban STAR program service areas will no longer have the option to use the Primary Care Case Management model for Medicaid-covered health care services, according to the Texas Health and Human Services Web site. HHSC began the withdrawal of the PCCM model, also known as Texas Health Network, from the San Antonio, Dallas, El Paso, Houston-Galveston and Lubbock areas in July. New Medicaid patients in these areas must move to an HMO by mid-November or else they will be assigned to one.

The PCCM model requires Medicaid enrollees to choose a primary care physician to provide primary and preventive care services and refer to sub-specialists when necessary. If patients currently on a PCCM plan don’t choose an HMO with which their doctor has a contract, there is a chance that they will lose their physicians.

PCCM patients should have received HMO enrollment information in August, and physicians can help inform them of HMO options in their area. In October patients who have not transitioned to an HMO will receive a reminder letter to complete the switch. HHSC asks primary care physicians to maintain each client’s medical home throughout the transition.

General Medicaid questions can be directed to the Texas Medicaid and Healthcare Partnership contact center at (800) 925-9126.

---

Study predicts physician shortage

Enrollment in U.S. medical schools should be increased 30 percent by 2015 to ensure quality health care for an aging and growing population, according to a new report by the Association of American Medical Colleges.

AAMC bases the recommendation on a projected population growth of 25 million people each decade and a doubling in the number of people over 65 between 2000 and 2030. The next generation to hit their 60s, 70s and 80s are the aging baby boomers, and besides that group wanting quality care to stay active in their later years, the large batch of baby-boomer physicians who currently make up one in three of health care providers are likely to retire by 2020.

“Given the extensive time it takes to educate and train tomorrow’s doctors, efforts to increase enrollment must get underway as soon as possible to ensure that the health care needs of the nation in 2015 and beyond are met,” said AAMC President Jordan J. Cohen in a press release.

To accommodate additional U.S. medical graduates in teaching hospital residency training programs, the AAMC calls for increased public support of graduate medical education, specifically removing the cap on the number of residency positions funded by Medicare.

For more information, read the official AAMC Statement on the Physician Workforce at www.aamc.org/workforce.

---

Claims processing software shorts physicians on payments

By AAFP News Staff

Fix the software. That was the Academy’s message to two health insurance payers that have raised the ire of some family physicians who aren’t getting paid for urinalysis testing for patients when the test is performed during an evaluation and management visit.

Letters recently went out to Mark MacDougal, vice president of TRICARE Claims Services, and Chris Jagmin, M.D., Aetna’s medical director for policy and administration, asking them and all other payers, to “respect the care provided by family physicians and pay them for performing a urinalysis on the same day as an office visit … and update your claim logic software accordingly.”

According to the letters, Aetna’s McKesson Clear Claim Connection™ software and TRICARE’s ClaimCheck® system both bundle payment for CPT code 81003 with an E&M service when provided on the same day.

Calling it “inappropriate” for payers such as TRICARE and Aetna to bundle a urinalysis as “incidental” (similar to giving a patient an adhesive bandage) to an office visit, AAFP Board Chair Mary Frank, M.D., of Mill Valley, Calif., gave concrete reasons for the Academy’s stance.

First and foremost, “dip urinalysis is important to good patient care,” and it is routinely used to check for protein or albumen during pregnancy and in patients with diabetes, said Frank. It’s also a useful tool in deciding on an appropriate treatment for a urinary tract infection.

In addition, said Frank, the bundling of urinalysis with E&M services is contrary to CPT instructions. “CPT directs physicians to report urinalysis separately from E/M services when both are provided to the same patient on the same date.”

Bundling payment of the urinalysis with the office visit disregards the fact that the urinalysis represents a physician practice expense, said Frank. The total estimated cost to the physician for the urinalysis strip test is $4.65 — $4.16 for labor and $0.49 for supplies — continued Frank, and that estimate doesn’t include the indirect expenses the practice must apportion over all services provided.

Frank compared two diagnostic tests to make her point. “The urinalysis process is similar to venipuncture preparation for which there is a separate billable code,” she said. “Urinalysis is an expense separate from the E&M service that is not included in the valuation of E/M services. … This is why Medicare and other payers — who appropriately use the resource based relative value scale — pay urinalysis separately from E&M services.”

Source: AAFP News Now, Sept. 12, 2006. © 2006 American Academy of Family Physicians.

---

Dealing with insurance company hassles? Check out online toolkit

A handy new online toolkit — Payment for Same-day Preventive and Acute Services — is available to family physicians looking for solutions to combat insurance company payment denial.

“This particular payment issue is a very common complaint communicated by members,” said Trevor Stone, private sector advocacy specialist in the Academy’s Practice Support Division. Some insurance plans argue that payment shouldn’t be expected for an overlap in services; however, “the Academy views preventive care and significant acute care services as separately reportable services — even when given on the same day — and (family physicians) should be paid accordingly,” said Stone.

AAFP’s Committee on Practice Enhance­ment called for the development of the toolkit, which is perhaps better defined as a compilation of resources on the topic that has been developed during the past few years.

“The Academy wants health plans to follow CPT guidelines on this issue,” said Stone, and the committee “wanted to make it easy for members to access all the materials that have been developed over the past few years that support that stance.”

A sample of resources found at the site include archived articles from Family Practice Management such as:

• “Same-Day E/M Services: What to Do When a Health Plan Won’t Pay,” April, 2006;
• “Getting Paid: Are You Prepared to Defend Your Coding?” June, 2005; and
• “Getting Paid: Understanding When to Use Modifier -25,” October, 2004.

Several letters regarding same-day preventive and acute care services appear in the “Tools” section in template format and are available for members to download and use. The templates provide a quick and easy way for members “to deliver a clear and concise argument to insurance payers, patients and employers,” said Stone.

The toolkit’s placement in the policy and advocacy area of the Academy’s Web site signifies the Academy’s ongoing efforts on members’ behalf in the private sector advocacy arena.

Source: AAFP News Now, Sept. 19, 2006. © 2006 American Academy of Family Physicians.

---

AAFP provides tobacco cessation tools to members

Smoking cigarettes can damage nearly every organ in the human body, it is linked to at least 10 different cancers including lung cancer, the most preventable form of cancer in our society, and it accounts for 30 percent of all cancer deaths in the United States. All family physicians have heard these warnings about smoking, published by organizations such as the American Cancer Society, but primary care physicians have a unique ability to counsel patients on whole-body health and influence their tobacco use.

AAFP launched the project Ask and Act to give physicians the tools to identify patients who smoke and help them quit. The project consists of CME and an online toolkit containing lapel pins, prescription pads, wall posters, quitline referral cards, other patient education materials and information on physician payment for tobacco cessation counseling.

To request an Ask and Act toolkit and for more information, visit the Ask and Act section on AAFP’s Web site or contact AAFP’s Mary Theobald at mtheobal@aafp.org.