Private health insurance companies have long since required patients to pay higher out-of-pocket fees when they see physicians who are not in the insurers’ contracted physicians network. In a more recent development, they have begun to rank physicians according to quality and cost parameters and offer enrollees lower out-of-pocket charges if they see physicians who fare better on these parameters.

In such programs for example, a doctor shown to order fewer imaging tests that are of questionable value would rank in a higher category.

Physicians have always objected to these practices. A March article in the New England Journal of Medicine brought the issue to a boil by showing that these tiered rating systems misclassified 22% of all doctors.

The study prompted provider organizations to release a letter protesting the payer’s practices. “Physicians’ reputations are being unfairly tarnished using unscientific methodologies and calculations,” the letter claimed.

“There are serious flaws in health insurers’ programs to try to rate individual physicians,” AMA President Cecil Wilson added in an interview with the Wall Street Journal.

The provider organizations implored payers to reevaluate their ranking programs.

Payers’ reactions to the letter were lukewarm. For example, Cigna told the Journal that its doctor-rating program already addressed issues raised in the study by focusing on physician groups rather than individuals. Besides that, “Some physicians do provide higher-quality or more-efficient care, and it makes sense to provide modest incentives for choosing that care,” said Dick Salmon, the company’s VP for network quality.

A spokesperson for WellPoint responded it has “taken a thorough, thoughtful approach in introducing measures of physician quality and cost effectiveness” and that the effort is “collaborative with the physician community.”

Training program directors and patient advocates have voiced concerns for years that residents who toil for long shifts on-the-job could harm patients because fatigue increases the risk they will make errors of one sort or another.

A 6 year-old study by the Accreditation Council for Graduate Medical Education gave credence to their concerns by showing that the fatigued residents  caused more than half of all preventable adverse events.

In response, the ACGME recently proposed strict new guidelines which would, if adopted, curtail the duration of residents’ shifts and increase supervision requirements for those in charge of their care. The plan extends previous initiatives by the ACGME to limit the work hours of residents.

The new guidelines were published in the New England Journal of Medicine and are subject to a 45-day public comment period.

The fundamental components of the ACGME’s proposal are 16-hour shift limits for first-year residents and 24-hour limits for those in later years of training.  Current rules permit residents to work for as many as 30 consecutive hours.

Also included are instructions about the supervision of interns by residents, and beefed-up monitoring and enforcement of the guidelines including annual site visits of each program.

In a replay of what happened the last time ACGME addressed the subject, some physicians and patient advocacy groups said the new guidelines didn’t go far enough. These groups pointed out that the guidelines weren’t as far-reaching as the changes recommended by the Institute of Medicine in 2008.

Meanwhile, some physicians argued the new limitations would impede the educational process and result in more errors…the kind that occur during hand-offs in care at the ends of shifts. Hopefully, some well designed studies of the matter can add value to the debate once (and if) the new guidelines go into effect.

To help offset a drop in Harvard University’s enormous endowment, Harvard Medical School has cut a deal with its affiliated teaching hospitals that calls for the hospitals to contribute $36 million to the school over the next 3 years.

The figure represents but a fraction of the medical school’s $580 million budget, but it may signify the onset of a new kind of relationship between the school and its affiliates.

Before the deal, Harvard was probably the only medical school in the country that didn’t derive financial support from its teaching hospitals. The school does not own its teaching hospitals, as do most others.

The peculiar arrangement means Harvard Medical School has been unusually dependent on government research funding and endowment income, which exhibit cyclical variations beyond the control of the school.

The ongoing worldwide financial crisis thus hit Harvard Medical hard: Harvard University’s endowment fell by 27%, to $26 billion during fiscal year 2009. That caused a 20% reduction in endowment income for the medical school.

In response, Harvard Medical School froze salaries and dropped 70 FTEs from its labor force via layoffs and early retirement in 2009. It expects to break even in the current fiscal year, but needs more money to expand programs and develop new ones so it can maintain its exalted status.

At a meeting last summer involving medical school dean Jeffrey Flier and teaching hospital execs, Massachusetts General Hospital CEO Peter Slavin said Flier “had to convince us this is the fairest thing to do.’’

Although the Harvard teaching hospitals are profitable, insurers, politicians and regulators are all pressuring them to cut costs.

In return for their largesse, the hospitals asked the medical school to handle physician promotions more quickly, among other things.

Last week, the American Board of Internal Medicine sanctioned 139 physicians for sharing test questions and answers from the board’s certification test.

The move came a few months after the ABIM sued New Jersey-based Arora Board Review for theft of trade secrets and copyright infringement. The sanctioned physicians had disclosed actual board questions to Arora while participating in one of its exam prep courses.

ABIM and Arora reached a settlement in the case in which Arora’s manager agreed not to offer a live board review course. Terms of the agreement did not require Arora to admit wrongdoing.

ABIM CEO Christine Cassel told AMedNews that her organization became aware of the issue after stumbling upon copyrighted exam questions on Arora’s website.

“At the Arora Board Review courses, [the manager] was not only bragging that he had ABIM questions but soliciting people who remembered questions to report them back to him,” Cassel said.

Physicians must sign a “pledge of honesty” 3 separate times during the exam. The pledge warns test-takers not to disclose, copy or reproduce test-related material, and threatens penalties for those who do.

Camille Miller, the lawyer who represented Arora in the suit, said that Arora disagreed with ABIM’s actions. “Physicians routinely discuss examination content with others,” she said. “ABIM has not apparently enforced this consistently against other physicians.”

Penalties levied by ABIM against the physicians may include revocation of board certification or suspension of certification for up to 5 years depending on the particular offense. Noncertified physicians would need to wait for a year or more before retaking the test.

The physicians have 2 months to appeal the ABIM’s decision. After that, the board will start notifying state medical licensing boards of its actions.

US News & World Report’s influential “top 50” list of US hospitals is driven by subjective reputations of the institutions rather than objective measures of hospital quality, according to a study by Ashwini Sehgal of Case Western Reserve University.

To establish subjective reputations of US hospitals, US News surveys 250 board-certified physicians from around the country. US News also uses objective data including nurse-to-patient ratios, availability of specific medical technology, risk-adjusted mortality for Medicare patients, and teaching status.

In analyzing the relative contributions of subjective vs. objective measures in determining which hospitals made the coveted list, Sehgal “found little relationship between rankings and objective quality measures for most specialties.”

Specifically, he found a strong correlation between a hospital’s rank in the US News list and the hospital’s “reputation score” as measured in the survey. By contrast, a hospital’s rank was variably correlated with the objective scores used by US News.

For example, the top five heart and heart-surgery hospitals based on reputation score alone were the same as those of the US News top five heart hospitals (Cleveland Clinic, Mayo Clinic–Rochester, Johns Hopkins University, Massachusetts General Hospital, and the Texas Heart Institute).

“Because reputation score is determined by asking approximately 250 specialists to identify the five best hospitals in their specialty, only nationally recognized hospitals are likely to be named frequently,” Sehgal told MedScape. “Users should understand that the relative standings of US News & World Report’s top 50 hospitals largely indicate national reputation, not objective measures of hospital quality.”

“Being well-known may be the result of many factors that are unrelated to the quality of day-to-day care,” commented Harlan Krumholz of the Yale University School of Medicine.

The write-up is in the Annals of Internal Medicine.

Physicians often have negative attitudes regarding obesity, and many express dissatisfaction about caring for obese patients. Meanwhile, obese patients often feel their physicians are disrespectful or biased against them because of their appearance.  Such observations raise concern that obese patients may receive lower quality care than non-obese patients.
 
Thankfully however, a recent study by Virginia Chang and colleagues from the University of Pennsylvania has shown that medical care for obese patients is at least as good, and in some instances marginally better than that provided to other patients.

To reach these conclusions, Chang’s group compared physicians’ performance on 8 common outpatient quality measures for obese vs. non-obese patients. The study population included 36,122 patients from the Medicare Beneficiary Survey (1994-2006) and 33,500 patients from the Veterans Health Administration (2003-2004).

The scientists tracked performance for diabetes care (eye examination, glycated hemoglobin testing and lipid screening), pneumococcal vaccination, influenza vaccination, screening mammography, colorectal cancer screening, and cervical cancer screening. Data were obtained from administrative claims, survey data and chart review.

Overall, they found no evidence to suggest that obese or overweight patients received “recommended care” less frequently than normal-weight patients. In fact, obese patients received recommended care for lipid screening (72% versus 65%) and glycated hemoglobin testing (74% versus 62%) more frequently than normal-weight diabetic patients.

“Even though physicians might harbor negative attitudes towards obese patients, it doesn’t seem to be borne out in the quality of care they’re delivering,” Chang told MedPage Today. “So I think both physicians and patients can feel some degree of relief on that front.”

The write-up appears in the Journal of the American Medical Association.

The Senate Finance Committee is investigating patient deaths and allegations of substandard treatment at the Select Medical Corporation, a for-profit company that operates 89 long-term care facilities, making it the largest organization of its kind in the nation.

Long term care hospitals treat about 200,000 seriously ill patients per year, although they rarely employ full-time physicians. The facilities are defined solely by their length of stay, although they also tend to be smaller than acute care hospitals and do not have emergency rooms.

In a letter sent to Robert Ortenzio, the CEO of Select , the committee’s top two senators, Montana Democrat Max Baucus and Iowa Republican Charles E. Grassley demanded that his company provide records concerning staffing levels and turnover, and patient monitoring and the quality of care at its facilities.

The letter is not a subpoena, but companies typically respond voluntarily to things like this.

A New York Times article prompted the investigation. The article described poor treatment and several deaths at long-term care hospitals, including one owned by Select in which a dying patient’s heart alarm rang for 77 minutes before nurses showed up.

Former employees of Select told the Times that Select’s hospitals are understaffed, and that the company tries to keep patients for exactly 25 days since the most profit can be obtained by patients who stay for this duration, according to government reimbursement rules. 

Select spokesperson Carolyn Curnand said her company would cooperate with the Senate investigation. She said the Times article was misleading and inaccurate and that her company had a record for providing high quality care. She denied that Select discharged or held patients for financial purposes.

The Ortenzio family has made $400 million since starting Select 14 years ago.

Medical students begin losing empathy after their first year in school, and the decline accelerates after clinical rotations, according to a study in Academic Medicine.

To reach these conclusions, Bruce Newton and colleagues followed 419 medical students from four consecutive classes from freshman through senior year at the University of Arkansas for Medical Sciences.

Researchers assessed vicarious empathy, which is a person’s emotional response to the perceived emotional experiences of others. Using a 9-point scale, they asked students to agree or disagree with statements like, “I cannot feel much sorrow for those who are responsible for their own misery.”

The scientists found that student empathy scores dropped after the first year of medical school and then again after the third year. Female students turned in higher empathy scores than their male counterparts, and students entering primary care showed more empathy than those entering pathology, radiology and surgery.

They attributed the early decline in empathy to stress and anxiety associated with students’ competitiveness and worry about exam scores. The late decline was assumed to be caused by the intensity of hospital practice. Teaching on the wards was likely to have been rushed, and students may not have received as much mentoring or bedside teaching as they wanted.

“We know that really good communication skills (helps) patients…to comply with the instructions of the physician,” said Newton. “A bond of trust is established, and if something unfortunately goes wrong, if you have this bond, you are less likely to be sued.”

“We start with students who are very caring but have no diagnostic skills and end up with physicians with great diagnostics skill but who don’t care,” summed up Richard Frankel a professor of medicine at Indiana University School of Medicine, for AMedNews.

Diabetic patients treated by physicians who received pay-for-performance incentives received better care and had better clinical outcomes than those whose physicians were not involved in the program, according to researchers at IMS Health.

To reach these conclusions, Judy Chen and colleagues looked at the records of diabetic patients who received care from the Hawaii Medical Services Association, a large PPO between 1999 and 2006. HMSA had 19,600 diabetic at study onset and about 32,000 by 2006.

HMSA offered its physicians the opportunity to earn bonuses ranging between 1.5% and 7.5% of their base fees if they met quality-of-care targets including the use of HbA1c and LDL cholesterol testing for their diabetic patients. Beginning in 2001, participating physicians could earn nearly $6,000 in bonuses if their adherence to specified care requirements improved versus the previous year.

The provider organization defined high-quality care as receiving at least 2 tests for HbA1c and one test for LDL cholesterol in a given year.

Chen’s group found that physicians who were enrolled in the P4P program delivered high quality care 16% more frequently than physicians who were not so enrolled. The patients of physicians who participated in P4P for at least 3 consecutive years were also found to be 25% less likely to be hospitalized.

“This study showed a robust, consistent, significant, and positive association between increased receipt of appropriate laboratory monitoring of A1c and LDL cholesterol levels and decreased hospitalization rates,” Chen’s group wrote.

The proportion of diabetic patients seen by physicians enrolled in the P4P plan jumped from 79% in 1999 to 95% in 2006.

The write up is in the American Journal of Managed Care.

Physicians must follow certain protocols should they wish to dismiss a patient in their practice.

Physicians can ask chronically disruptive or drug-seeking patients to leave their practice. They can do the same for patients who miss appointments or fail to pay bills, but generally they can’t fire patients for simple failure to follow their advice.

Recently, some pediatricians began refusing to care for the children of parents who don’t let them be vaccinated based on fears of a link between vaccines and autism.

The American Academy of Pediatrics frowns on this, Douglas Diekema, a former chairman of its bio-ethics committee told the Wall Street Journal, “because it gives you the opportunity to continue the discussion. Two years later, if the child gets whooping cough, the parents may change their mind.”

State laws on the subject are variable, but in general they require that doctors document the reason for withdrawing care, inform the patient about the problem, give him or her time to find a new physician and then send a certified letter ending the relationship.

The right of doctors to refuse to treat patients was reaffirmed by the Fifth Circuit Court of Appeals, in a case involving John Bower, the director of a kidney dialysis program in Jackson, Mississippi.

Bowers’ patient frequently missed appointments for dialysis, drank excessively and ended up needing emergency care all the time.

Bower eventually told the patient he was ending the relationship, but an advocacy group sued. Bower argued that forcing physicians to treat patients violated the 13th amendment, which outlawed slavery.

He won the case, but ended up treating the patient anyway because his hospital received funds under provisions requiring its physicians to treat anyone that needed care.

The patient died in a car accident 4 years later.

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.