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I received a letter the other day. It was from one of the health care insurance companies. The sum and substance were complimentary. I was designated a high quality physician according to their performance standard evaluation. After a few microseconds of self congratulation I realized that I was being graded by the insurer, which was not something I felt too comfortable with. I downloaded the information regarding their “Performance Program” methodology. To quote the web-site: “The program works as follows. All physicians who are in good standing with their licensing authority and with the Physician Data Sharing program are included in the program assessment process. An individual physician’s performance related to 20 common chronic conditions is reviewed against evidence-based guidelines, and for physicians who perform invasive or surgical procedures, rates of complication are analyzed. Physicians who meet the quality criteria are then evaluated for their efficiency in the use of health care assets. Those physicians with sufficient claims volume for evaluation, and who meet the program criteria for both quality and efficiency, receive the ______ Performance designation.” At first blush this seems pretty reasonable. Why not reward good work with a better rating? The methodology outlined on the next several pages goes through the steps in rating us.
“Proceduralists” who perform a minimum of ten inpatient procedures during the three months of review are looked at according to local geographic benchmarks for complications.. “Non-Proceduralists”with a minimum of ten cases such as Congestive Heart Failure, Diabetes, Chronic Back Pain, Asthma, MS, Depression, and multiple other medical diagnoses are compared to Evidence Based Medicine (EBM) guidelines. “Physicians receiving an aggregate score of 65% compliance with the EBM guidlelines are eligible to move to the next step in the assessment process-the efficiency analysis. ”Efficiency is how much your care costs the insurance company from the start of the patient’s care for a “discrete diagnostic condition (episode) from the onset of symptoms until the treatment is completed.” Fifteen completed episodes during the 3 months are compared with the average cost for similar episodes. If you are average you get a _______Performance designation and a five pointed star goes next to your online and printed physician directories. The 3MTM and IngenixTM software looks at the claims and lets everybody know if you are a performer or an outlier, letting your patients know if they should see you or someone else. Similar methodology has been used for years and will be used by Medicare and others if bills being presented to Federal and State legislatures are passed. New York is one of 13 pilot states for the health care insurer evaluating the program. So what else does this program have in mind? Steering patients to pay, co-insurance and deductibles to see you will decrease if you don’t get your star. Will you get paid more if you get a star? “Physicians receiving the _____Performance designation will continue to be reimbursed in accordance with the terms of their current participation agreement.” In other words you’ll still get paid your reduced fee if you get the star, but if you don’t you’ll lose patients, and be labeled a poor perfomer. So, if you’re a sub-sub-specialist and all your patients have complex problems with poor compliance, and you get more complications you may not get your star if the software doesn’t factor this in too well. Since you are not getting paid for undertaking more complex cases and are now being penalized for taking care of them, will doctors in a plan send difficult patients elsewhere? A long time ago a statistics professor told me that you could make statistics tell you what you wanted the outcome to be. While the goals of improving physician performance and patient outcomes is desirable, the people compiling and analyzing the data have been less than trustworthy in the past. We can’t be asleep at the wheel while the bureaucracies of health care insurers and governmental agencies put methodologies in place which will fundamentally change our practice of medicine. How will spending time listening to patients with anxiety, depression and psychosomatic problems be compensated when giving a drug is more efficient? How much less efficient will we be, by caring about our patients and understanding their problem? Will personalizing care for our patients, who fall outside of the statistical constructs of software manufacturers, make us “poor performers?” While all of us want a star, isn’t it our duty to do the right thing for our patients, not the “cook-book” treatment that statistical averages demand. Watch out! Big Brother isn’t just watching. He’s telling on you. Arnold S. Prywes, M.D.
If a physician intends to implement a policy of charging patients for missed appointments the physician should first determine if the physician’s contracts with the applicable payors allow the physician to charge the patient. Many of the contracts that providers enter into with the numerous payors have language that states the physician may charge a patient for an uncovered service provided that the physician has advised the enrollee that the service is uncovered and the patient will be responsible for the payment of the service. Provided the contract has this or similar language the physician must then determine if the applicable payor treats missed appointments as a non-covered service.Once the physician has checked all applicable contracts, the physician should create an effective date and post a prominent notice for all to see near the office cashier (i.e. from mm/dd/yy forward, patients will be charged $xx.xx for missed appointments that are not cancelled within 24 hours of the scheduled time. This charge will not be covered by any health plan). This is consistent with MSSNY’s current position on the subject. The policy reads as follows: 240.994 Reimbursement for Missed Appointment: MSSNY, consistent with the current opinions of the AMA Council on Ethical and Judicial Affairs, Section 8.01, reaffirms the position that "A physician may charge a patient for a missed appointment or for one not canceled 24 hours in advance if the patient is fully advised that the physician will make such a charge. The practice, however, should be resorted to infrequently and always with the utmost consideration for the patient and his/her circumstances." (HOD 96-263)
Legislation (A.2943,Gottfried/ S.764, Hannon) to extend confidentiality protection to all statements made by persons in attendance at peer review committee meetings will be considered at the Assembly Health Committee on February, 15th. The measure would close a loophole which exists in the law that allows disclosure of such statements in the event that the person who made the statement becomes a party to a subsequent proceeding involving the matter reviewed at the peer review session. The bill is the same as last year’s amended version which narrowed the focus of the measure to peer review conducted in a hospital setting and created a new element of physician misconduct for the failure to “cooperate and participate reasonably and in good faith in the quality assurance, incident reporting and peer review programs” in such settings. MSSNY has written in support of this measure. We need to voice our support since Florida doctors’ peer review is now discoverable. We could be next!!
Form MR/IME-1 (Health Provider’s Application for Authorization under the Workers’ Compensation Law) was revised in June 2003 to include additional questions about a physician's license such as suspension, revocation, limitation, or restriction. The correct and current form to be using is MR/IME-1 (6-03). The WCB staff that works with these forms mentioned that the county medical societies were supposedly alerted to the revision and given a time frame during which the prior forms could continue to be used. After that time, the new forms would be required (i.e. (6-03)). The grace period was not defined. There may be some instances when current applicants have completed the old forms. Therefore, if CMS’ are receiving the old forms for new applicants, please be sure to return the application to the physician and ask that the newer form (6-03) be completed before forwarding the application and recommendation to the WCB.
The Greater New York Hospital Association (GNYHA) and 1199/SEIU this week released a “10-point plan” to reform New York’s health care system.
The groups recommended the creation of a State Fund to “provide a secondary layer of coverage, once hospitals and physicians have purchased a primary layer, thus spreading the risk across a wider base.” MSSNY has been working closely with GNYHA and 1199 on putting forth a comprehensive plan to control the cost of liability to providers. MSSNY has continued to urge the Legislature to enact legislation to reduce the costs of liability. The “10-point plan” also calls for measures which MSSNY has historically supported including: updating the medical provider reimbursement system and devotion of state resources for system-wide enhancements including most particularly, information technology that can help create efficiencies and enhanced quality. MSSNY however, has substantial concern with regard to two proposals including one which would impose an assessment on cosmetic procedures, similar to a New Jersey law enacted last year, and a second which would require “niche providers” (at this point undefined) to pay a fee to support general hospitals. MSSNY is continuing to review this proposal and will be continuing its discussions with these organizations, the Legislature and the Governor about how best to effectuate reform of New York’s health system. * * *
Several of MSSNY priority bills for 2005 have been re-introduced, including: A.2204 (Gottfried) – Would prohibit health plans from including certain offensive provisions in contracts with participating physicians, including "most favored nation" clauses. Referred to Assembly Health Committee. A.2205 (Gottfried) – Requires physician who performs utilization review for a health plan to be in the same or similar specialty as the physician who recommends treatment to a patient. A.2210 (Gottfried) – Provides notification of an external appeal to an enrollee’s designee and their health care provider. A.3106 (Sweeney) – Limits to 180 days the time within which a health plan may make a refund demand from a physician in the absence of suspected fraud. Referred to Assembly Insurance Committee. Identical bill expected to be introduced in the Senate shortly. A.3155 (Karben)/S.1505 (Morahan) – Requires insurers to permit patients to assign benefits to their treating physician. Referred to Assembly and Senate Insurance Committees.
NASSAU
COUNTY MEDICAL SOCIETY Special Guest Speaker Ed Lowe Retired NEWSDAY Columnist; Contributing columnist for the Long Island Press; Telecare TV panelist; Radio program host; Author' Raconteur; Humorist. Tuesday, March 29, 2005 Dinner and presentation - 7:00 pm T he Chateau Briand Restaurant44 Old Country Road, Carle Place, NY Seating is Limited - Response Required Click here for a PDF version of the response form - Please Fax to 516 - 832 - 2323 by March 21, 2005.
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At
the 2004 House of Delegates, the House passed Resolution 2004-274 which
directed MSSNY to encourage physicians to review the pertinent contract
to ensure that billing a patient for missed appointments is not
prohibited.
MSSNY’s
Socio-Medical Economics Division Director Regina McNally recently
received notice from a county medical society that was having
difficulties with applications being returned by Workers’ Compensation
Board (WCB) staff. 
As
discussions regarding the 2005-06 State Budget begin to unfold,
physicians are urged to contact their legislators to advise them of the
need to fully restore the cut enacted in the 2003-04 State Budget that
reduced the reimbursement to physicians who treat patients eligible for
both Medicare and Medicaid. Physicians can send a letter to their
elected representatives in support of restoration by logging unto the
MSSNY Grassroots center at 