Medicare has stopped paying claims to Miami-based Fernando Mendez-Villamil, MD, until it can figure out whether his prolific prescription writing is legit. The psychiatrist has written 96,685 prescriptions to Medicaid patients over the last 21 months.

That works out to an astonishing clip of 150 prescriptions per day, 7-days per week. It is nearly twice as many as the runner-up prescriber, Huberto Merayo, whose office is just a few blocks from the Prescription King.

In fact, the top 7 prescribers of mental-health drugs in the state all reside in the Miami-Dade area.

According to the Miami Herald, Miami-Dade is at or near the top, depending on the measure, of the most expensive places to get health care in the nation.

“While the state is investigating, we haven’t paid his claims,” Medicare spokesman Peter Ashkenaz told the Herald. Apparently, Medicare cut off the spigot last May.

The story hit the press after Charles Grassley, a Republican Senator from Iowa released a letter he had written to Medicare and Medicaid officials in which he inquired about their procedures for detecting over-utilization of medical services. The letter didn’t mention Mendez-Villamil by name, but did cite the number of prescriptions he had written.

The Herald used the astronomical number to trace the allegation back to Mendez-Villamil.

The psychiatrist told The Herald that he prescribes only drugs that are medically necessary, that he works long hours, averages 10 minutes per patient visit, and many of his patients are taking 4 or 5 drugs.

Grassley’s letter, it should be noted, concerned only Medicaid prescriptions. No one seems to know how many scripts the prolific psychiatrist penned for patients covered by Medicare.

The health reform “debate” (such as it is) has highlighted our nation’s PCP shortage, but there’s another area where the demand for MD-level services outstrips supply: pediatricians trained in sub-specialties like gastroenterology, rheumatology, and developmental -behavioral medicine.

NACHRI, the National Association of Children’s Hospitals and Related Institutions recently briefed Congress on the matter, in an attempt to favorably influence the “debate.” 

A recent survey of its members, NACHRI officials said, revealed widespread shortages in multiple pediatric specialties which have forced 90% of member’s facilities to delay appointments.

What is more, members reported that vacancies for specialty pediatricians often remained unfilled for more than a year. The most severe shortages are in cardiology, oncology, hematology and developmental-behavioral medicine.

The latter shortage is of particular concern in light of the recent spike in autism-related disorders. Half the members in the survey reported delays of more than 3 months before getting to see a developmental specialist as a result.

Part of the explanation for the shortage is the woefully inadequate compensation these specialists receive. It amounts to just more than half the haul raked in by their counterparts in adult care.

In this regard, a provision in the House bill which requires Medicaid to pay Medicare rates for office visits would really help, NACRI officials say. NACHRI is also lobbying for increased funding for specialty training and a loan-forgiveness program.

In Pediatrics, specialization requires 2 to 3 years of training after the general pediatrics residency is completed. 

“While most of us are driven into this profession because we love kids, the vast majority leave training with huge debt and the prospect of not making very much money at the end,” John McBride told the Wall Street Journal. McBride is a pediatric pulmonologist at Akron’s Children’s Hospital Medical Center.

If given the opportunity, most female surgeons would choose the same career again, even though it had a major–and not altogether positive–impact on their lives, according to a study in the Archives of Surgery. 

For the study, Kathrin Troppmann and colleagues from UC Davis mailed surveys to all 3507 surgeons that received certification from the American Board of Surgery in the years 1988, 1992, 1996, 2000 and 2004.

The scientists received 895 responses; 178 from women, and 698 from men.

Although both sexes reported they worked too much, more than 82% of female respondents and 77% of male respondents said they would choose their profession again. More than 75% of the female surgeons and 91% of the male surgeons were married

Female surgeons were less likely to have children (64% vs 91%) than their male counterparts, and tended to have their first child at an older age—after they had entered practice. Men tended to have their first child during residency.

For 27% of female surgeons, the spouse was their child’s primary caretaker. The spouse of male surgeons assumed these responsibilities nearly 80% of the time.

Female surgeons were more than twice as likely to assert that time-off for child-rearing was important after the birth of a child, and that child care should be available at work. Only 9% of females and 3% of males actually took time off after the birth of a child.

“A career in surgery has significant lifestyle implications: the profession is associated with high degrees of patient acuity, significant on-call responsibility, and irregular work hours, all requiring a significant commitment of personal time,” wrote the authors.

They concluded that strategies to increase recruitment and retention of female surgeons should include flexible work schedules and improved maternity leave and child care options.

Why do you suppose physicians frequently prescribe medications for non-FDA approved uses?

A recent survey has confirmed the worst possible reason ends up causing a lot of it: physicians simply don’t know what the FDA has approved, and what it hasn’t.

That’s the discouraging news from a study designed by G. Caleb Alexander and colleagues from the University of Chicago to characterize physicians’ knowledge of the FDA-approved indications of commonly prescribed drugs.

The scientists found in particular that a nationally representative sample of PCPs and psychiatrists knew the correct FDA-approval status for only 55% of drug-indication pairs.

That dismal performance increased to 60% for drugs actually prescribed by the physicians within the last year.

In the study, physicians were asked to complete a questionnaire focusing on 14 common drug-indication pairs, which varied with respect to FDA-approval status and level of supporting evidence. Subjects were asked to indicate whether each pair had FDA approval.

The drug-indication pairs included valproic acid for bipolar disorder and mania, gabapentin for diabetic neuropathy, Lexapro for panic disorder, trazodone for insomnia, Seroquel for dementia with agitation and Effexor for adjustment disorder.

41% of subjects believed that at least one drug-indication pair with uncertain or no supporting evidence had FDA approval, as is the case for the use of Seroquel in patients having dementia and agitation.

Psychiatrists showed better knowledge of FDA approval status than PCPs (66% vs 42%).

“These results indicate an urgent need for effective methods of disseminating information to physicians about the level of evidence supporting off-label drug uses, with specific attention to common off-label uses known to be ineffective or to carry unacceptable risk of harm,” concluded the authors.

The write-up appears in Pharmacoepidemiology and Drug Safety.

More than a third of surgical residents think that regulations designed to limit their work schedules to a maximum of 80 hours per week represent a “significant barrier” to their training. And 43% of them want to work more hours than the regulations permit.

To reach these conclusions, Jacob Moalem and colleagues at the University of Rochester distributed a Web-based survey to all surgical residents and associate members of the American College of Surgeons.

Of the nearly 600 respondents, 41% said the rules were a “considerable or moderate barrier” to their training. Less than a third said the rules did not hinder their training. An additional 27% said the rules were a minimal barrier.

Senior residents were more likely to view work time restrictions as a barrier to their training, regardless of whether they trained at small, medium, or large programs.

The write-up appears in the Journal of the American College of Surgeons.

“Surgeons are expressing a desire and a need to learn more in a compact time frame,”  Moalem told BurrillReport. “Senior surgery residents should be given the chance to control their own schedules as they continue to refine their technical skills and transition into independent practice.”

The regulations had been implemented to address resident burn-out and improve patient safety. It had been the norm for surgical residents to log 100+ hours per week before the change.

The regulations have been shown to increase the number of hours residents sleep each week, and there have been anecdotal reports that their personal lives have improved, but their effect on caseload, academic performance, and board scores is not well understood.

Beyond this, some studies have suggested that the shorter work-weeks have led to more communication errors caused by more frequent patient handoffs, according to the scientists.

Back in August, 2005, physicians at Urological Associates ordered 9 CT scans for patients covered by the local BCBS carrier. They ordered 8 in September. That rate was lower than most physicians in the community.

But in October, the Iowa-based group ordered 35 scans and then 41 and 55 in the ensuing 2 months. That was about 3 times higher than local norms.

The sudden jump began when the practice purchased its own CT scanner, according to the Washington Post, and the tale repeats itself all over the US. 

The bump in imaging does not translate to improved health outcomes, as numerous studies have shown.

And the excessive radiation from the scans may cause up to 1% of all cancers in the US.

The self-referral problem was thought to be solved in 1992 with passage of the Stark Law, but a loophole allowed physicians to keep up the practice, so long as the devices were housed under the same roof as their practice.

The exception was intended to permit physicians to use the machines for expedited diagnoses of fractures, pneumonia and the like, but soon after Stark passed, CT and MRI scanners shrank magically in size.

“Physicians who purchase machines for their offices have a financial incentive to refer patients for additional services,” MedPAC stated in a recent report. “Physician ownership could influence the judgment of some physicians, particularly when there is not strong evidence to guide their decisions.”

Meanwhile the Web site of GE Healthcare posts testimonials from physicians about the nifty return on the imaging devices. “We’re already beating our pro forma in terms of the return on investment,” says one West Virginia physician.

Congress, by the way, is considering a proposal to prohibit the practice.

In the old days, patients could do little when physicians kept them waiting, blew-off their questions or seemed incompetent. A tale of woe over the phone to friends or family, or if things got really bad, a complaint to the state medical board was all they could muster.

The Internet has changed that. In the last 5 years, several dozen Web sites have cropped up where patients can post reviews of their physicians, and the chatter on such sites has been louder than the birds at Bodega Bay.

“The worst doctor I have ever encountered in my life,” ranted one consumer. “Impolite, unengaged and unfocused,” chirped another. “Long wait, rude staff, never sent me a follow-up on my tests.”

The most popular physician rating sites, according to the Washington Post, are RateMDs.com, DrScore, Yelp, and Vitals.com.

They support themselves via ad revenues from Google and they’ve become a force.

RateMDs.com for example, has ratings on more than 200,000 physicians and attracts a million unique visitors per month, not to mention the wrath of physicians.

“The people least capable of judging quality of care are patients,” argued Washington DC internist Nancy Falk. “They don’t know what we know.” 

“Doctors aren’t like dishwashers or trash compactors or minivans,” agreed orthopedic surgeon Peter Lavine. The sites, he told the Washiington Post, “attract patients who have an axe to grind.” 

Meanwhile, ethicist Arthur Caplan worries the sites don’t focus on care outcomes, which he insists is the most important consideration.

“One person’s brusque is another’s direct,” Caplan told the Post. “Many doctors who score well on ambiance are not good doctors… (I’ve seen) doctors who were well beyond the border of malpractice who kept going because patients loved them.”

The Centers for Medicare and Medicaid Services announced last Wednesday that it was changing its payment rates to providers in 2010.

The new rates will increase payouts to beleaguered primary care practitioners while snubbing radiologists and cardiologists, among others.

Among the perks for PCPs, CMS has proposed a bump in payments for the Initial Preventive Physical Exam, a.k.a. the “Welcome to Medicare” visit to reflect the true complexity of the service.

CMS also proposed to change the way Medicare recognizes professional liability expenses such that Medicare’s support for these costs is redirected to providers experiencing the highest malpractice premiums.

Beyond that, the news was gloomier than Boston’s weather this June. 

CMS is, for example, proposing to remove physician-administered drugs from the definition of “physician services” and to stop paying for consultation codes, which are typically billed by specialists at a rate higher than procedurally similar evaluation and management (E/M) services. 

Overall, the changes would increase payments to GPs, family physicians, internists, and geriatric specialists by 6-8%, according to a CMS press release. The biggest losers will be radiologists, especially interventional radiologists who should see cuts of at least 20% for most imaging tests.

Payments to cardiologists would be cut about 11% overall, with cuts of up to 42% for reading an echocardiogram and 24% for performing cardiac catheterization.

Cuts “like this threaten the successes we have had over the years with reducing heart disease,” ACC president Alfred Bove warned the Wall Street Journal.

Meanwhile Ted Epperly, president of the American Academy of Family Physicians, said the CMS proposal would drive more medical students into primary care, and hailed the pay raise for his constituency as “long overdue.”

Industry sources have told the Washington Post that 3 influential hospital associations have agreed to contribute $155 billion over the next decade toward paying for the costs of insuring the 47 million Americans that don’t currently have coverage.

The deal reached between the American Hospital Association, the Federation of American Hospitals and the Catholic Health Association and both White House officials and Senate Finance Committee leaders follows a similar deal in which Big Pharma coughed up  $80 billion toward the same end.

“Getting health-care reform is absolutely critical,” said a hospital association negotiator. “This is our attempt to act in good faith.”

About 60% of the savings would result from cuts to previously expected Medicare and Medicaid payments. Most of the rest would be achieved by reducing hospital payments earmarked for care of the uninsured.

The reductions would kick-in after most uninsured folks acquire coverage, a significant risk-mitigator for hospitals.

A source privy to the negotiations indicated the parties reached a deal after government officials pitched “shared responsibility” and assured providers that that all parts of the system would be asked to sacrifice.

In achieving the final figure, the Big O played hardball, just as he did with Big Pharma 2 weeks earlier. In that case, Obama floated a request that drug makers fork over $100 billion towards the greater good. After losing its lunch, Big Pharma countered with $80 billion and the deal was done.

In this case, the Coronated One announced in his weekly radio/Internet chat that his team had found ways to save $200 billion in hospital costs over a 10 year period.

“There was no way we could tolerate $200 billion,” an industry executive told the Post.

The American Hospital Association has urged constituents to oppose a proposal by the Senate Finance Committee that would require hospitals to provide “a minimum annual level of charitable care” in order to obtain or keep their tax-exempt status as charitable organizations.

The proposal would prevent tax-exempt hospitals from refusing service to those unable to pay for it, and require them to follow specific procedures before initiating collection activities against patients.

Hospitals found to violate the rule could lose their tax-exempt status or be slapped with excise taxes by the government.

Currently non-profit hospitals pay no federal income tax, and can access government-issued tax-exempt bonds. They can also receive tax-deductible contributions. The Congressional Joint Committee on Taxation believes these tax breaks are worth more than $6 billion per year.

“Ask your senators to oppose the charity care proposal,” read the bold type in an AHA bulletin released last week.

“A formulaic, one-size-fits-all charity care standard will hamstring hospitals’ efforts to respond to the unique needs of their communities,” it continued.

“It would penalize children’s, teaching and research hospitals and those in rural areas because they provide community benefit in a variety of forms other than just charity care.”

The new standards were floated by Finance Committee chairman, Max Baucus, a Montana Democrat, and Iowa’s Charles Grassley, the senior-ranking Republican on the Committee.

Mr. Grassley reasoned that hospitals received “a tremendous advantage” from their tax-exempt status, but don’t always provide enough charity care to justify it.

Grassley, for the life of him, couldn’t see why the AHA was raising such a ruckus on the matter. “If, as a result of health care reform, everyone has health insurance, presumably hospitals should see a steep decline or the elimination of uncompensated care,” Grassley reasoned to the New York Times.

Readmissions to hospitals, defined as a second admission within 30 days of hospital discharge for the same or a similar medical condition, cost Medicare $17 billion per year.

Many readmissions can be prevented by coordinating post-discharge care more effectively and implementing simple home monitoring programs.

The problem is that when hospitals implement such programs, it sets them back financially. Payers like Medicare reap all the benefits. 

Take Park Nicollet Health Services, for example. The Minnesota-based hospital and clinic system has long-since established a reputation for its innovations in the quality of care. Four years ago, the provider began spending $750,000 per annum on nurses and special software to reduce readmissions for congestive heart failure.

The program reduced such readmissions from 16% to 4%.

The program saved Medicare $5 million per year, but Park Nicollet received not a cent for its efforts. In fact, fewer admissions for the condition actually cut revenues for the intrepid quality leader.

“We’ve kept it up out of a sense of moral obligation to these patients, but we’re getting killed,” Park Nicollet’s chief executive David Wessner told the New York Times.

“We have a reimbursement system for health care that is not aligned with providing high-quality care,” said Barry Straube, Medicare’s CMO. “Unequivocally, there has to be payment reform.”

Michael Connelly, chief executive of Catholic Healthcare, which has similar programs, says payers need to bundle payments for a hospital stay and the follow-up care.

“One of my frustrations is it’s taking so long to do this,” he told the Times. 

“Hospitals who say they are penalized for doing the right thing are right,” concurred Robert Berenson, a policy analyst at the Urban Institute. “If we can’t do this, we can’t do much of anything in health reform.”

Hospitalized Medicare beneficiaries are far less likely to be seen in house by their PCP than they were 10 years ago, according to Gulshan Sharma and his team at the University of Texas medical Branch of Galveston.

The findings raise concern about continuity of care as various payment reforms and the hospitalist movement change longstanding routines.

The scientists reported that in 1996, 51% of hospitalized Medicare patients were seen by at least one physician that had seen them as an outpatient in the preceding year.

In 2006, that number had dropped to 40%.

To reach these conclusions, the scientists utilized a retrospective cohort trial design involving 3,020,770 hospital admissions from over a 2 year period, representing a 5% national sample of Medicare beneficiaries.

The write-up is in JAMA.

Using multivariable, multilevel models, the scientists ascribed about a third of the lost continuity to the hospitalist movement. Medicare payment formulas discourage PCPs from visiting their hospitalized patients when hospitalists are on the case.

Patients admitted on weekends, or who lived in large metropolitan areas or in New England experienced greater losses in contact with their outpatient physicians during the study period.

For its study, Sharma’s team posited that continuity of care included 3 dimensions: continuity in information, continuity in management, and continuity in the patient-physician relationship.
 
The team recommends further study to determine whether the reduced continuity of care has detrimental effects on patient outcomes, and that interventions be developed which would mitigate any such untoward effects.

West Penn Allegheny Health System claims it’s losing its shirt because its larger rival, the University of Pittsburgh Medical Center has colluded with Highmark, the area’s leading private insurer to drive it out of business.

So it filed suit in federal court against both of ‘em.

West Penn’s accusations cite numerous activities since 2002 that ensured Highmark’s dominance while guaranteeing juicy payouts for UPMC.

“West Penn is running out of options,” Jan Jennings commented to the Pittsburgh Post Gazette. The CEO of American Healthcare Solutions added, “you don’t sue UPMC and Highmark, with the deep reserves of cash they both have, unless you’re desperate.”

UPMC released a statement saying it “unequivocally denies the allegations,” and that the filing is an attempt by West Penn Allegheny “to divert attention from (its) operating and financial difficulties.”

Last year, WPA took a $73 million write down caused by an overestimation of revenues derived from patient care. A month ago, the system reported operating losses of $9.1 million and a Q4 2008 net loss of $5.6 million.

Highmark officials announced they were “surprised and disappointed” by the lawsuit, while citing their recent$125 million loan to West Penn and multiple grants they provided to “strengthen (West Penn’s) administrative and information systems.”

West Penn claims the 2 organizations have “engaged in mutual back-scratching designed to preserve Highmark’s monopoly in health insurance and to permit UPMC to build a monopoly in sophisticated … health care in this region,” according to David McClenahan, its board chairman.

“I can’t judge the arguments. I just know these kinds of cases in general are very hard to prove,” Jennings opined.

In 2006, Massachusetts enacted a law that vastly reduced the number of uninsured Bay State residents. There was one slight problem though. Scads of the newly insured couldn’t find primary care doctors to take care of them.

Wait times for routine office visits have soared in some parts of the state to 100 days and many residents have simply given up trying to find one.

These folks end up seeking care in ERs which is what they did before they were covered.

The problem scares the bejeesus out of officials in the Obama administration, who know that if the Big O has his way and 40-50 million Americans acquire health insurance in the blink of an eye, the same problem will play itself out nationwide.
 
What to do? Some suggest bumping medical school enrollment which would begin addressing the problem around the time the Big O wraps-up his second term, and that’s assuming any of the new graduates actually enter primary care.

Others recommend increased utilization of nurse practitioners and physician assistants, but last time we checked all these types are already happily employed, and training new ones is associated with lag time problems of its own.

Solutions with a quicker onset of action include expanding RN-staffed retail clinics with leveraged physician oversight, and opening the doors even more widely to foreign medical graduates.

Some even suggest overhauling the payment structure for physicians in a way that incents specialists to do some primary care.

Assuming policymakers have the stomach to take on physician payment reform in a way that doesn’t cause system-wide costs to skyrocket, the idea won’t go down well with specialists, regardless.

Listen to Peter Mandell, for example. The spokesman for the American Association of Orthopedic Surgeons told the New York Times, “we have no problem with financial incentives for primary care (but) if there’s less money for hip and knee replacements, fewer of them will be done for people who need them.”

The chairmen of 13 clinical departments at Boston’s Beth Israel Deaconess Medical Center agreed last week to donate $350,000 to help reduce the need for staff layoffs.
 
“This was a really easy decision,” Mary Ann Stevenson told the Boston Globe.

The Radiation Oncology chair added, “most of us have been longtime campaigners for the hospital. Most of us feel really strongly about where we work.”

And they’ve appealed to their physician colleagues and reports who are affiliated with the hospital to follow suit.

“We invite you to consider making as generous a contribution as possible,” the chiefs penned in a letter to 1,100 staff physicians that was obtained by the Globe. Donated funds “will support job preservation among the hospital staff (so) they can continue to provide great service to our patients.”

Beth Israel Deaconess is affiliated with Harvard Medical School. It announced last month that it faced a $20 million operating loss for the fiscal year, and planned to enact cost-reducing moves including RIFs as a consequence.

After that announcement, hospital CEO cum blogger extraordinaire Paul Levy began working with employees on money saving, job preserving ideas.

That let BIDMC reduce the number of layoffs from 600 to 150.

The ideas included a temporary halt in funding employees’ 401(k) and 403(b) retirement plans, suspending a planned 3% salary increase for certain employees, eliminating the annual employee barbecue and ending hospital reimbursement for staff cell phones.

In addition, Levy has cut his own pay by 10%, and that of his executive staff by 5%.

Hospitals across the country have seen patient volumes drop as the Great Economic Crisis prompts people to defer elective procedures. Inpatient volume at BIDMC is off 1% this year.

Fifteen percent of all hospitalized patients experience at least one adverse drug reaction during their stay, and each ADR adds about 0.25 days onto the length of stay, according to Munir Pirmohamed and colleagues at the University of Liverpool.

To reach this conclusion, the scientists tracked the hospital stays of 3,695 consecutive patients admitted to 12 hospital wards during a 6-month stretch in 2005.

They reviewed charts to assess causality, severity and preventability, and performed multivariate analysis to identify ADR risk factors.

In all, 545 patients experienced at least one ADR. The report is in Plos One. 
 
The most common ADRs included bleeding, constipation, confusion, renal problems, and nosocomial infections involving Clostridia, Staph and other potentially life-threatening bacteria.  Half of all ADRs were felt to be definitely or possibly preventable.

The most commonly offending drugs were narcotic analgesics, anticoagulants and diuretics.
 
The number of drugs being taken by a patient turned out to be the most significant predictor of ADRs, with each additional medication multiplying the risk by about 14%.

Elderly people, who tend to be taking many medications, were therefore found to be at high risk for ADRs.
 
“Our results show that the overall burden of ADRs on hospitals is high and therefore new methods of intervention are needed to reduce this,” Pirmohamed told BurrillReports. 
 
“We are currently looking at…ways of improving the safety of medicines, including increased monitoring…and identification of genetic factors that increase the risk of…adverse effects,” he added.

Other groups, particularly Boston’s Institute for Healthcare Improvement have made progress in this area. Even so, IHI estimates there are as many as 15 million incidents of medical harm each year in US hospitals.