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22-07-2012 | Article

The week in review, July 15-21, 2012

MedWire News: This week's stories concern unease among both US physicians and governors over the future of healthcare, poll results showing that a majority of US residents are beginning to accept the Supreme Court's judgment on the Patient Protection and Affordable Care Act, the growth of Accountable Care Organizations, efforts to push preventive care, and a poor showing for "Safety-net" hospitals.

Governors mull snub of federal generosity

Although the US Government would pick up the tab for nearly all of the expansion of Medicaid planned under the Patient Protection and Affordable Care Act (PPACA), several state Governors appear reluctant to take advantage of the largesse.

Many Republican and some Democratic Governors appear to be on the fence about providing coverage to millions more poor and low-income residents through expansion of Medicaid, a federal program administered through each state, The Washington Post reports.

Montana Governor Brian Schweitzer, a Democrat, told The Post that although the federal Government would foot most of the bill for extending Medicaid coverage to 84,000 Montanans, an increase of 54.5% in the state's Medicaid rolls, he is concerned that the state would have to go into debt to meet its obligations.

Part of the uncertainty stems from the US Supreme Court's landmark decision upholding the legality of the PPACA. Although the Court upheld the law's provisions governing the expansion of Medicaid, it added that neither the legislative nor executive branches of Government have the power to punish states that do not comply with the law by withholding all Medicaid funding.

The Justices did rule, however, that the federal Government may withhold new Medicaid funds from states that are not in compliance with the law when it is fully enacted in 2014.

It is likely that despite their objections to implementing the law, many states will ultimately decide to accept the federal funds, because failure to do so would place a financial strain on state resources.

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Docs peer into cloudy crystal ball

A survey of US physicians suggests that many are apprehensive about the immediate future and feel overburdened by administrative issues.

At the same time, the majority accept the benefits of electronic medical records (EMRs), but seem to be lagging behind other professionals in their use of communications technologies, according to a survey conducted by the physician directory little blue book, and the consumer health interactive website Sharecare.

A total of 1190 physicians representing more than 75 specialties responded to the survey. In all, 71% said they expected a decline in the quality of healthcare over the next 5 years, and 41% said they looked to state-based rather than national advocacy organizations for support. A full 40% of respondents, however, reported feeling that "no one is advocating for me."

In addition, 81% of respondents said they felt that administrative tasks related to patient care were one of the biggest clinical challenges they faced. Slightly more than half (55%) said they had trouble spending adequate time with each patient, one-third (33%) reported challenges in communicating with other clinicians, and nearly as many (31%) said they had difficulty keeping up with the latest clinical developments.

Among the most frequently reported practice management challenges were obtaining reimbursement from insurers (reported by 80% of respondents), administrative burdens of patient approvals (77%), integration of EMR or other systems (66%), and inability to see enough patients in a day (38%).

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Get on with it already!

The majority of US residents say that they want opponents of the Patient Protection and Affordable Care Act to stop trying to block implementation and move on, according to a Kaiser Family Foundation poll.

A nationally representative sample of 1239 English and Spanish-speaking residents from all 50 states showed that 56% agreed that "opponents of the law should stop their efforts to block the law and move on to other national problems," whereas 38% said that opponents should continue trying to block the law from being implemented, and 7% said they did not know, or refused to answer the question.

Democrats overwhelmingly supported the law (82%), as did independents who identified themselves as "leaning" Democratic (78%). Additionally, 51% of independents with no expressed party preference said that lawmakers should get on with the rest of the nation's business.

By contrast, 69% of both Republicans and Republican-leaning independents said they wanted opponents to keep trying to dismantle the healthcare law.

Although Republican hostility to the law continued unabated in the days immediately following the Supreme Court ruling to uphold it, there was a "surge in Democratic enthusiasm for the law," the pollsters say, with the percentage of Democrats who reported having a very favorable opinion of the law climbing from 33% before the ruling was announced, to 47% afterward.

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ACOs sign up

The Medicare Shared Savings Program has added another 89 Accountable Care Organizations (ACOs) to its ranks, the Centers for Medicare & Medicaid Services (CMS) has announced.

As the name implies, ACOs assume the financial risk and, presumably, can reap the benefits of providing care at a fixed per-patient cost.

The newly selected ACOs will be responsible for the care of close to 1.2 million Medicare beneficiaries in 40 states and the District of Columbia, bringing the total number of ACOs participating in the Medicare Shared Savings Program to 154, and the total number of patients served to approximately 2.4 million.

Five of the newly enrolled ACOs have applied for a higher-risk, higher-reward version of the savings program. These organizations will share in the savings if they manage to keep costs down, but will also be liable for losses should the cost of care for their patients increase beyond their allotted amounts.

The Shared Savings Program was created as part of the Patient Protection and Affordable Care Act. Coordinated care provided through ACOs is expected to reduce costs by ensuring that patients receive timely preventive care, diagnosis, and treatment, and by reducing duplication of services and medical errors.

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Log in for an ounce of prevention

An online, interactive portal may boost patient adherence to preventive care measures, a new study suggests.

Among 4500 patients from eight primary practices, 2250 were randomly assigned to use an interactive preventive health record (IPHR) and the remainder to receive usual care. Those who used the record (16.8%) used significantly more recommended preventive services, such as colorectal, breast, and cervical cancer screening, report Alex Krist (Virginia Commonwealth University, Richmond) and colleagues.

"Patients who were mailed an invitation to use the IPHR were more likely to be up-to-date on all indicated preventive services than were patients who received usual care. When IPHR users were compared with nonusers, the benefits appeared to be substantially greater. In fact, at 16 months, 1 in 4 users were up-to-date on all preventive services ‑ nearly double that of nonusers," the authors write in the Annals of Family Medicine .

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Medicare payments stress primary care, prevention

The Centers for Medicare & Medicaid Services (CMS) have proposed changes to Medicare payment policies and payment rates for physician-provided services.

"In recent years, CMS and HHS [the Department of Health and Human Services] have recognized primary care and care coordination as critical components in achieving better care for individuals, better health for populations, and reduced expenditure growth. Accordingly, CMS has prioritized the development and implementation of a series of initiatives designed to ensure accurate payment for, and encourage long-term investment in, primary care and care coordination services," according to a CMS statement.

For 2013, CMS has proposed creating a procedure code that takes into consideration the extra resources required when community-based physicians coordinate their patients' care within 30 days of discharge from a hospital stay, skilled nursing facility, or certain outpatient services.

The proposed procedure code would compensate physicians for care management services other than face-to-face visits.

However, the proposed rules change also has the potential to reduce reimbursements to radiologists who provide intensity-modulated radiation therapy (IMRT) and stereotactic body radiation therapy by reducing the time assumed to be required for each procedure.

Other proposed changes include a reduction in payments for second and subsequent surgical procedures performed by the same physician or practice on the same day, a "face-to-face" requirement for payment of some high-cost durable medical equipment expenses, and additions to the Medicare list of approved telehealth prevention services.

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"Safety-net hospitals" are second-rate

So-called "safety-net hospitals" (SNHs) provide second-class care, results of a study suggest.

SNHs, defined as US hospitals with a disproportionately high share of elderly patients on Supplemental Security Income and Medicaid, scored lower than non-SNH hospitals on nearly all patient-experience performance measures, report Ashish Jha (Harvard School of Public Health, Boston, Massachusetts, USA) and colleagues.

Patients in SNHs were significantly less likely to give good overall scores on a 10-point global measure of patient experience than their peers in other hospitals (63.9 vs 69.5%). In addition, SNH patients were significantly less likely to have received discharge information or to report that they always communicated well with their physicians.

The findings are important because the CMS's value-based purchasing (VBP) program penalizes poor quality hospitals, the investigators note in the Archives of Internal Medicine.

"Given that hospital payments are now tied to performance on these measures, we need renewed efforts to track performance of SNHs under VBP and may need specific quality-improvement programs targeting these organizations," Jha et al write.

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By Neil Osterweil