In the News for the Week of 8-8-06
The business of medicine
- Internists' salaries on the rise
Health information technology
- Government approves new protections for HIT
- House bill aimed at helping physicians convert to electronic systems
- New 2007 hospital prospective payment amounts announced
- Apply now for your national provider identifier
Clinical news in the headlines
- ACP Journal Club: Self-monitoring improves outcomes for patients on oral anticoagulation therapy
Flu vaccine update
- FDA approves new formulation for upcoming season
Health care disparities
- Hispanics and African-Americans less likely to have health insurance
The business of medicine
Rebounding from several years of stagnation, salaries for general internists spiked upward last year, according to the latest national survey.
Internists' annual compensation rose by an average of 3.5% between 2005 and 2006, according to Modern Healthcare magazine’s annual Physician Salary Survey, published in the July 17 issue. Average annual compensation for internists ranged from $161,200 to $192,000, depending on the organization collecting the data, and averaged $177,000.
Hospitalist salaries increased even more, up to 12%, bringing their annual compensation to between $147,200 and $198,020. Modern Healthcare’s physician salary report is based on data collected independently by 15 different national recruiters and trade associations.
While salaries for specialties outside of internal medicine stayed flat, the survey found, specialists still are among the most highly paid professionals in the nation. Among the top earners were orthopedic surgeons, with average total cash compensation of about $403,000 in 2006, and orthopedic specialists, who earned nearly $489,000, followed by radiologists (average pay of $394,000), noninvasive cardiologists ($370,000; invasive cardiologists were not tracked), urologists ($340,000) and anesthesiologists ($333,000).
Despite the recent increase, primary care physicians remain at the bottom of the salary scale. Family physicians earned an average of $165,000 in 2006, up 3% from last year. Pediatricians earned about the same as family physicians after seeing a slightly higher average annual increase—3.4%.
Researchers who conducted the survey speculated demand for hospitalists is driving up salaries for internists across the board. Another factor is an increasing shortage of general internists as more graduating physicians choose subspecialties over primary care.
Modern Healthcare’s 2006 Physician Salary Survey is online.
Health information technology
New federal rules allow physicians to accept donated e-prescribing and electronic health records (EHR) software and hardware from hospitals without running afoul of fraud and abuse laws, as long as they pay a percentage of the cost.
Both HHS’s Office of the Inspector General (OIG) and Centers for Medicare and Medicaid Services (CMS) announced the new “protections” on Aug. 1. The rules are published in the Aug. 8 Federal Register.
Current fraud and abuse laws prevent physicians from referring Medicare patients for certain services to hospitals with which they have financial ties. As a result, hospitals have been hesitant to give physicians computer equipment and software that would be used to transmit patient data back and forth between physician offices and hospitals, according to the Aug. 1 Modern Healthcare. The new rule would allow such a transaction to occur, so long as the recipient physician pays 15% of the cost of the donated EHR technology items and services.
In the new rule, CMS and OIG stipulated that the protections relating to EHRs will expire on Dec. 31, 2013, with the assumption that protection will no longer be needed by that time because technology will have become a widely used part of medical practice. All donations of items and services related to electronic health records must occur by this date.
In previous comments to CMS and OIG on the proposed rules, ACP stressed the importance of providing protections in order to encourage the adoption of these new technologies, and encouraged moving forward on the final rules as soon as possible.
In letters to CMS and OIG, Joseph Stubbs, FACP, chair of ACP’s Medical Service Committee, commended the then-proposed rules. “Donors and recipients need to have the necessary comfort to engage in these types of arrangements," he said, "and the final rule should do nothing to discourage such engagements.”
HHS’s press release on the new safe harbors is online.
Modern Healthcare is online.
The House of Representatives recently voted to pass the “Health Information Technology Promotion Act of 2006” (H.R. 4157), a bill designed to assist physicians move toward full-scale adoption of interoperable health information technology.
In a July 26 letter to Speaker of the House, Dennis Hastert, ACP President Lynne Kirk, FACP, encouraged passage of the bill and specified several provisions that ACP considers especially important, including:
- Authorization to create the Office of the National Coordinator of Health Information Technology (ONCHIT) and clear definition of the duties of that office;
- Creation of a clear safe harbor to the federal anti-kickback statute and an exception to the self-referral law; and
- Authorization to study and reconcile the variation of state and federal standards established under the Health Insurance Portability and Accountability Act (HIPAA).
The related bill in the Senate, S. 1418, the “Wired for Health Care Quality Act,” is significantly different from the House version, with the major difference involving a substantial commitment in the Senate bill for federal grant funding. In addition, the House bill contains a provision mandating conversion to ICD-10 by October 2010. ACP is opposed to this mandate. It remains to be seen whether the House and Senate can reconcile the two versions when they return from summer recess in September.
In her letter, Dr. Kirk noted that ACP “will continue to work for provisions that would include financial and reimbursement incentives to physicians, particularly those in small practices." Much of the savings recognized from a fully integrated HIT system flows to payers, she added, not the physician practice absorbing the initial start-up and ongoing maintenance costs.
The full text of Dr. Kirk’s letter is online.
Medicare’s 2006-07 inpatient prospective payment system will shift some money—but significantly less than originally proposed—from highly specialized services, such as heart surgery, to more routine services, such as treating pneumonia. The new fee system takes effect Oct. 1, 2006.
Overall, average payment rates will increase by 3.5% to all hospitals, said the Aug. 3 New York Times. Only hospitals that report quality data will be eligible to receive the full increase to their payment rates. Hospital pay also will be adjusted to better account for the severity of a patient’s condition, according to CMS, which announced the final rule on Aug. 1. Some hospitals, particularly cardiac-specialty hospitals, are expected to experience decreases.
In a major change from the proposed rules, implementation of the new system will be phased in over three years, rather than all at once. That means, according to CMS, that only 2% of hospitals have a projected reduction in payment, and no hospital will see cuts of more than 5%.
The original rules proposed by CMS sought double-digit cuts in many cardiac and orthopedic procedures. But following an intense lobbying campaign by hospitals and medical-device companies, CMS reduced the payment cuts and lengthened implementation time.
The final rule also reduced the increases originally proposed for treating other conditions, including pneumonia and chronic obstructive pulmonary disease. The new system changes many diagnosis-related groups (DRGs), identifying 20 new DRGs and modifying 32 to better capture differences in severity. These are interim steps, said CMS, in preparation for more comprehensive changes in 2008.
A CMS news release is online.
The New York Times is online.
If you don’t already have one, now is the time to apply for a National Provider Identifier (NPI).
In less than a year—by May 23, 2007—all large health plans will be required to use only the NPI to identify covered healthcare providers in standard HIPAA-covered transactions. Small health plans must use only the NPI by May 23, 2008.
When physicians apply for their NPI, they should include all their legacy identifiers, not only for Medicare but for all payers, and if reporting a Medicaid number, make sure to include the associated state name. CMS says this information is critical to aid payers in the transition to the NPI and to ensure that physician claims aren't held up or bounced because the doctor couldn't be identified.
The new NPI system is expected to simplify health care transactions by allowing providers to use one identifier with all health plans.
Clinical news in the headlines
A review of trials comparing self-monitoring with physician-management of oral anticoagulation therapy concluded that self-testing and management reduces the risk for major adverse events.
The review compared outcomes of trials where patients were managed by primary care physicians or in specialized anticoagulation clinics with patients who self-monitored. Researchers found fewer thromboembolic events, major bleeding episodes and deaths in the self-monitoring groups than the professionally managed groups.
Patients in the self-management group also had a higher proportion of tests in the international normalized ratio (INR) target range. The studies are abstracted in the July-August ACP Journal Club.
Fewer complications occurred whether patients self-tested and had dosage adjusted by their physicians or both self-tested and self-adjusted their dosage, noted Journal Club reviewer John M. Spandorfer, FACP, of Jefferson Medical College in Philadelphia. Just as diabetic patients have improved control through self-monitoring, he said, patients undergoing anticoagulation are learning that self-monitoring using point-of-care prothrombin time devices can improve anticoagulation control.
However, effecting widespread self-monitoring is problematic, said Dr. Spandorfer. For example, self-management patients should be highly motivated with sufficient manual dexterity and adequate vision. Patients also must receive professional training on equipment use and the effects of warfarin.
Reimbursement is another challenge as Medicare currently only reimburses for anticoagulation monitoring associated with mechanical valves, said Dr. Spandorfer. The findings of this review may improve the reimbursement outlook for patients needing long-term anticoagulation.
Peer ratings for this review: General internal medicine, family practice, general practice, 5/7 stars; hospitalists, 6/7 stars; hematology/ thrombosis, 5/7 stars.
ACP Journal Club is online.
Flu vaccine update
The FDA last week approved this year’s flu vaccine formulation, giving manufacturers enough time to produce about 100 million doses for the 2006-07 flu season.
Four vaccine manufacturers have permission to market their vaccines in the U.S.: Chiron Vaccines, GlaxoSmithKline Biologicals, MedImmune Vaccines, and Sanofi Pasteur.
This season's approved formulation for the U.S. vaccine is identical to that recommended by both the World Health Organization and FDA's Advisory Committee. The formulation includes one strain that was used in last year's vaccine and two new strains.
According to the CDC, 5%-20% of the U.S. population gets the flu each year, more than 200,000 people are hospitalized from its complications and approximately 36,000 people die after contracting the virus.
Health care disparities
Nearly two-thirds of all working-age Hispanic Americans and one-third of African American adults lack health insurance, according to a new report from The Commonwealth Fund.
The uninsured rate for these American adults is 1.5 to three times greater than it is for white Americans, nearly 20% of whom were uninsured at some point during 2005, said an Aug. 1 Commonwealth Fund news release.. The study also found that Hispanics and African Americans were particularly unlikely to have employer-sponsored insurance, compared with whites: 34% of Hispanics and 53% of African Americans got their health insurance from their employers, compared with 71% of white Americans.
The study found that Hispanics were “particularly disconnected" from the system, said the release. Hispanics were substantially less likely than whites to have a regular doctor, to have visited a doctor in the past year, or to feel confident about their ability to manage their health problems. About two-thirds (62%) of Hispanic adults in the U.S. lacked health insurance in 2005.
African American adults, meanwhile, were significantly more likely than whites to get their non-urgent care in emergency rooms and to report problems with medical debt, according to the study. The study found that 33% of African American adults went without health insurance at some point during 2005.
The study is available online.
The Commonwealth Fund news release is online.
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A 67-year-old man is evaluated for a 6-month history of worsening exertional dyspnea. He has severe COPD, previously with minimal exertional symptoms, but now notes activity-limiting shortness of breath when walking short distances. He does not have chest pain, gastrointestinal symptoms, or sleep-related symptoms. Medical history is otherwise unremarkable. Medications are a twice-daily fluticasone/salmeterol inhaler and an as-needed albuterol/ipratropium metered-dose inhaler. He has a 55-pack-year smoking history but quit when COPD was diagnosed. Following a physical exam, chest radiograph, and transthoracic echocardiogram, what is the most appropriate diagnostic test to perform next?
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