Cart. Horse. Whatever.

Priyanka Dayal McCluskey at the Boston Globe writes:

Attorney General Martha Coakley is renegotiating a controversial settlement with Partners HealthCare after a state commission said Wednesday that a proposed takeover of two North Shore hospitals would raise costs and increase Partners’ already formidable market power.

I'm trying to figure out how the Attorney General, who has documented for years that the market power of Partners has been a massive force for health care cost and price increases in the region, could have proceeded in the first place with her "antitrust" deal that would have allowed them to take over these additional hospitals.  And, if she had any doubts, why would she have negotiated the deal before the state commission finished its review?

Instead, notes the story:

Coakley had structured the deal, announced in May, so that it could be revised based on findings of the Health Policy Commission, a watchdog agency.

My readers may not know that I spend a great portion of my life teaching and advising on negotiation.  Let's just say that the negotiation technique employed by the AG in this case is one that many people would find highly unusual.

Some cart before some horse just went down the road here in Massachusetts.  It would really be better if the the Attorney General withdrew from this process and let her successor start over again in January.

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Don't forget HOPE Award nominations

Please don't forget that nominations for the MITSS Hope Award are due by September 19.

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Here's one view about Medicare billing transparency

While others have dispassionately made the point that there are unexplained variations in Medicare physician billing data that warrant careful consideration when using such data, one doctor thinks CMS has devious motives.  He says, "I believe that the release of these data by CMS was an attempt by policymakers to sway public opinion against physicians and lessen our political power in Washington." I summarize without comment, but I welcome your reactions.

David F. Penson, Department of Urologic Surgery, Vanderbilt Center for Surgical Quality and Outcomes Research, at Vanderbilt University Medical Center, published an article in the journal Urology, called "The Hidden Agenda in the Release of the Medicare Physician Reimbursement Data."  (Volume 84, Issue 3, Pages 501–502, September 2014.) Excerpts: 

On April 9, the Centers for Medicare and Medicaid Services (CMS) released data on Medicare reimbursements made to individual health-care providers in 2012. The government claims that this was done for the sake of transparency, to reduce fraud, and to encourage Americans to seek high-value healthcare. Call me paranoid, but I cannot help but wonder if there might be something more here.

If the goal of releasing these data is truly to increase transparency, reduce waste, and help market forces to improve the efficiency of health-care delivery in this country, the data have to be complete and accurate. This, however, may not be the case. For example, if Medicare services provided by a number of health-care professionals are billed under a single provider, which may be the case in certain programs and/or clinics, that individual will have these services wrongly attributed to them. In cases where the individual physician did actually provide the services, the data do not account for differences in case mix, as some providers really do see sicker patients than others. To this end, these physicians may get reimbursed to a greater degree, but these larger amounts may be entirely appropriate. Finally, there are going to be cases where the data are just simply wrong. 

It is worth noting that, in reviewing the “frequently asked questions” page on CMS's website, I was unable to find a link for physicians to question the accuracy of their data. However, I do not think CMS is concerned with my opinions on these data.

So, if CMS is not interested in the physician's concerns about the accuracy or validity of the data, what are they concerned with? Certainly, I believe that there is likely some truth to their statements around increasing transparency, eliminating waste and fraud, and trying to empower patients to select high-value healthcare. That being said, I believe there is a hidden agenda here. The Medicare physician reimbursement data were released just weeks after the passage of yet another temporary legislative patch for the sustained growth rate (SGR) cuts to providers. The SGR cuts are always the focus of physician lobbying efforts and, ultimately, politicians are well aware of the negative fallout that would occur if these cuts actually went through. By showing the public just how much Medicare currently pays physicians, it may lessen the political fallout of letting the SGR cuts go through.

In addition, immediately after the release of the data, the media ran a number of stories showing how some of the highest Medicare billers were also some of the largest political donors in the United States. Was either of these events a coincidence? I do not know, but I doubt it. I believe that the release of these data by CMS was an attempt by policymakers to sway public opinion against physicians and lessen our political power in Washington. Ultimately, the clinicians must be the ones at the table informing the discussion on the effectiveness of treatments and defending our patients' right to access to these therapies. If policymakers can turn the public against physicians and neutralize the voice of organized medicine on Capital Hill, it will be easier for them make unilateral changes to the Medicare program in the United States that may lessen costs but may also end up hurting patients.

I suppose the good news is that the modern news cycle seems to get shorter and shorter and the media has already moved on from this story. That being said, the government will release data on physician payments from pharmaceutical and device companies this fall. I am certain physicians again will be the focus of negative publicity when this occurs. Ironically, Congress will be considering another SGR fix at precisely the same time. Coincidence? I think not.

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Alice in Wonderland had nothing on this CMS billing issue

Muriel Gillick provides a cogent description of some Medicare billing issues in nursing homes.  If you can provide an explanation for how this can exist side-by-side with federal rules that support extra payments to hospitals for proton beams and to doctors for use of femtosecond lasers for cataract surgery, you are eligible to become the next CMS administrator.

An excerpt:

It's thought to be perfectly reasonable for a physician to be paid $92 in 2015 for a nursing home visit for an acute medical problem such as a new pneumonia (code 99309). To merit this payment, the physician must provide documentation that he or she has taken 2 out of 3 possible steps: obtained a detailed history, performed a detailed physical exam, or engaged in “moderately complex” medical decision making. Only if the physician takes a comprehensive history, performs a comprehensive exam, and engages in highly complex medical decision-making can he or she bill with the code“99310,” earning the somewhat more generous sum of $136. For comparison, note that a gastroenterologist is paid on average $220 for performing a colonoscopy, a 20-minute procedure. 

No wonder physicians often respond to a call from the nursing home about a sick patient with an order to send the patient to the hospital for evaluation. Send a frail nursing home patient to the emergency room and he has, I would guess, about a 90% chance of being admitted. So instead of paying a physician an appropriate amount for making a visit to the nursing home and instituting on-site medical care, Medicare would fork out a minimum of $5774 (the base DRG payment) for a 5-day hospitalization, exposing the patient to the risk of iatrogenesis.

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Undisclosed financial ties

In a recent post about the controversy over the use and cost of femtosecond laser cataract surgery, I relied in part on an article in Review of Optometry.  In that article and my post, Dr. Eric Donnenfeld was quoted saying a number of positive things about this device and surgical technique, while other doctors took the opposing view.

What RO neglected to say, and what I failed to realize at the time, is that Dr. Donnenfeld is a consultant to Alcon, a manufacturer of this surgical device.  I found that disclosure here, from a recent continuing medical education conference.

RO also failed to mention that another doctor quoted in the story with positive comments about this technology, William Trattler, also has financial interests with Alcon.

Review of Optometry says it has the following mission:

Review of Optometry is committed to giving optometrists the information they need to provide their patients top-quality care in a personally rewarding practice environment. It is a magazine written for optometrists and by optometrists.

To be clear, there is nothing untoward about doctors having a financial relationship with equipment manufacturers, but it is wrong for a journal to fail to disclose such associations. Readers rely on authors and editors to make such associations evident.

It would also be wrong for a physician to fail to disclose such relationships to his or her patients, particularly when use of the equipment in question is associated with higher out-of-pocket costs to those patients. As noted in the RO article:

Any respectable OD would agree that communication is essential in virtually any patient relationship, but it’s particularly crucial with regards to what they can expect after femto cataract surgery, especially if those expectations—and their personal financial burden—is high.

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Bad math in the Midwest

With appreciation to the They Said What? website, we bring this example of some pretty poor math from the Cleveland Clinic:

What's wrong?  As the site notes:

Not only is 144,000 people not “1 out of 19 people in the United States.”  144,000 is barely 1 out of 19 people in greater Cleveland.

Fortunately, the underlying prevention message is valid, but I would have liked to have seen some indication in the infographic that many people can stop having colonoscopies after age 75, something noted by another prominent Midwestern health system.

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Don't drive home wet

We all expect our car’s airbag to work in the case of emergency.  So what happens when it has been automatically shut off without warning?

We thought something was wrong with the airbag shutoff switch in our 2012 Subaru Impreza.  We’d be driving along, and all of a sudden the passenger airbag would shut off, leaving the passenger unprotected.

So we called the dealer and had the switch checked (more than once!) No problem, we were told. Maybe the passenger shifted her weight and the switch turned off.

Then, this week, a service attendant mentioned that the on-off switch had nothing to do with weight. It was based on the amount of water in a person’s body.

The light went on in our minds. It turns out that the airbag would shut off after a few minutes when we were driving home from the beach and the passenger was wearing a wet swim suit or sitting on a wet towel! It would stay off until the seat dried out.

We checked this out. Here’s how one Subaru dealer explains this on their website:

Most Occupant Detection Systems measure the weight of the front seat passenger, to determine if the front passenger seat airbag should deploy.

All 2012 and 2013 Impreza and 2013 BRZ models use a new type of Occupant Detection System called Electrostatic Capacitance Sensor ODS. This system does not use weight to determine whether to turn the Occupant Detection System ON and OFF. 

The Electrostatic Capacitance represents a material's capability of storing an electrical charge. 

When water or anything with high moisture content is spilled on the front passenger seat cushion, the airbag is designed to remain OFF until the seat cushion is dry.  This will also be the case if the passenger has moisture on their clothing, such as rain-soaked pants or rain gear.  In each of these situations, the airbag status may remain OFF even if a passenger is seated.

Passengers are advised NOT to sit in the front passenger seat if the seat cushion is wet or if their clothing is wet. The best way to ensure proper operation is to keep everything off the front seat except a passenger. 

We don’t recall getting notice of this when we bought the car.  And it was clear that the service department staff didn’t always think of mentioning this system when an owner brought up the issue of the airbag cutoff. And if you search for “Subaru occupant detection system” or “Subaru passenger airbag shut-off” on the web, there is no official notice from the company.

There is no warning about this shut-off system on the passenger side visor. And, if you check the owner’s manual, there is nothing about this issue in the opening section’s safety precautions, although there is material about the speed and force of airbag deployment. Later, embedded on page 42, there is this advisory if you happen to turn to that page: “If the front passenger’s seat cushion is wet, this may adversely affect the ability to determine deployment.  If the seat cushion is wet, the front passenger should stop sitting on the front passenger’s seat. Wipe off water from the seat immediately, let the seat dry naturally and then check the SRS airbag system warning light.…”

Let’s say you’ve never noticed this “feature.” You’re driving home from the beach on a crowded highway at 60 mph with your family in a full car, and the passenger airbag shuts off. Perhaps you see the shut-off light suddenly illuminating. How exactly do you stop the front passenger from sitting in the front passenger’s seat? Perhaps you don’t even see the shut-off advisory light, in that you are focused on the holiday traffic. In either case, your passenger faces an unexpected hazard.

Many Subaru owners are outdoor types who will drive home after a jaunt to the beach or a hike in the wet woods. How many of them know they are in danger when they do so?

How and why did Subaru decide that this kind of automatic shut-off mechanism was superior to one based on body weight? Don’t they have an obligation to better inform the owners of these model cars? This is a product design lawsuit waiting to happen.

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