The Attitude Doc

Pennsylvania ponders final comments on proposed insurance deal

October 27, 2008 on 1:27 pm | In Uncategorized | Comments Off The end may be near for the nearly two-year wrangling over the merger of two large nonprofit health plans in Pennsylvania.

With its deadline having passed for the public to submit comments on the proposed Highmark-Independence Blue Cross merger, the Pennsylvania Insurance Commissioner's office says it expects to give, or not give, its blessing by Jan. 27, 2009.

Between now and then, Pennsylvania legislators will have their chance to weigh in one final time, and the commissioner's office will review public and lawmaker comments as it considers the merger, which was first announced on March 28, 2007.

Independence, based in Philadelphia, and Highmark, based in Pittsburgh, want to combine to create a Blues plan with an estimated 8 million members and $23 billion in annual revenue.

The combined company would be the third-largest Blues plan in the country by membership.

The U.S. Justice Dept. has given the merger the go-ahead, leaving final approval to Pennsylvania Insurance Commissioner Joel Ario.

After hosting a series of hearings this summer and receiving hundreds of pages of public comment, the department cut off the official public comment period Oct. 14.

In a note submitted that day, Henry Allen, senior attorney for the American Medical Association's Private Sector Advocacy unit, argued that the merger should be blocked based on the negative impact on potential competition. The letter was written in response to a request from Ario after Allen's testimony on behalf of the AMA at the Philadelphia public hearing.

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Guarding their treasure: Health plans try to hold on to financial reserves

October 20, 2008 on 1:20 pm | In Uncategorized | Comments Off As nonprofit health plans holding billions of dollars in surplus ask regulators to help them, some in organized medicine have joined the call for those insurers to at least account for why their reserves need to be so high.

"They've had certain nonprofit tax exemptions, they've been allowed to accumulate money, and we feel some of this money could be put to better use for the public," said Michael Sandler, MD, president of the Michigan State Medical Society.

Michigan is among the states where the debate has been especially heated because health plans have made requests to state government to help them out. While Michigan plans have sought favorable insurance regulations, plans in Pennsylvania have asked for permission to merge and New Jersey plans have sought permission to convert to for-profit status.

Opponents of those proposals, including doctors' organizations, have pointed to these plans' multibillion-dollar reserves as evidence that they aren't working in the public interest and don't need government help.

Goldman Sachs health care industry analyst Matthew Borsch estimates the 30 largest nonprofit Blues have a collective $37.5 billion in reserves, $20.3 billion higher than required by the BlueCross BlueShield Assn. According to state filings compiled by Borsch, those 30 Blues plans more than doubled reserves from $16 billion in 2002 to $36.2 billion in 2007.

"Surplus builds up, in part, because reimbursement to physicians falls," said William Custer, PhD, director of the Center for Health Services Research at Georgia State University. But "if you try to squeeze the insurer too much, they may not be able to stay in business."

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Divided by duty: While a doctor serves the country, the practice must still serve patients

October 13, 2008 on 1:13 pm | In Uncategorized | Comments Off Two days after Hurricane Gustav stormed through Louisiana, Col. Stephen Ulrich, MD, was at a National Guard base in Columbus, Ohio, wearing camouflage and flooded with paperwork. As the state surgeon for the Ohio guard, he got a call-up to review the medical records of 1,500 soldiers who would be helping with relief duties.

Meanwhile, about 55 miles east, the five other physicians in Dr. Ulrich's family practice were trying to conduct business as usual in their Zanesville and New Lexington, Ohio, offices. But first there was some scrambling to make sure Dr. Ulrich's patients were seen.

That wasn't a new challenge for this practice. Dr. Ulrich has been called away twice before -- once for three months, once for six. He served as a flight surgeon in Balad, Iraq, flying with aircraft crews, doing clinical work and flight physicals, and being "just a regular doctor."

Tours of duty can take a toll, not just on doctors going to the war zone but also on those left behind. Both groups must work together to adequately plan for the absence and notify insurers, affiliated hospitals and others.

The emotional stress also extends to both groups. "You listen to the news and just pray he's not in danger. We say a lot of prayers around here when he's gone," said Melody Field, a nurse practitioner for Dr. Ulrich.

This time, Dr. Ulrich spent only a few days in Columbus. As the soldiers left for Louisiana, he was back in his office.

When the National Guard calls a physician to duty in the Middle East, it provides several months' notice to allow for working out a plan for the practice, contacting patients and making arrangements, said Maj. Randall Short, a Guard spokesman.

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Is your EMR legal? A document can look like a medical record, but not meet the legal definition.

October 6, 2008 on 1:01 pm | In Uncategorized | Comments Off You might find your electronic medical record to be an efficient way to store patient data, but is that record legal? If it were subpoenaed, would it help you or hurt you in court?

These kinds of questions are emerging as more physicians go electronic. Federal Rules of Civil Procedure, approved by the U.S. Supreme Court in December 2006, not only make any electronically stored data discoverable in a trial, but also open up physicians to several new liabilities inherent in the detail electronic data provides.

For example, if a nurse records information under your login and password, and that information is incorrect, you could be the one held liable. Or the record's metadata -- the time stamp of who entered what when -- can dispute a doctor's version of events.

While EMRs are touted as a way to make life easier for physicians, health IT and legal professionals say they can make life miserable for a doctor who buys the wrong system, or uses it in the wrong way.

"Where these issues can raise their heads is somewhat unpredictable," said Reed Gelzer, MD, co-founder of Advocates for Documentation Integrity and Compliance, an advocacy and consulting group that educates physicians and health care entities on the legal EMR.

Dr. Gelzer said electronic records can save you when the record-keeping combines with the metadata to provide an accurate picture. But, as some recent cases of snooping hospital employees have proven, EMRs can also detect when someone violates HIPAA. And, just because an EMR creates something that looks like a medical record doesn't mean that document fits the legal definition of a medical record.

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Tenn. Blues reboots physician rating program

October 6, 2008 on 1:01 pm | In Uncategorized | Comments Off A retooled physician rating program became available to nearly 2 million BlueCross BlueShield of Tennessee members in September.

The Tennessee Medical Assn. still has concerns, said Russ Miller, senior vice president. But he said the design is improved over the one that rolled out in March and was put on hold.

TMA has not formally endorsed or supported the program. Members met with BlueCross and served on a Physician Advisory Panel that helped design the ratings system, Miller said.

At a fundamental level, physicians still aren't happy ratings are based on claims data, which come with inherent limitations, Miller said. The TMA would also like it to be simpler for doctors to correct bad information.

Currently doctors can review the records that contribute to their scores, but it falls to them or their staffs to find evidence to correct any errors. "We feel the administrative burden shouldn't be on the people being rated," Miller said.

Physician ratings programs elsewhere also have been canceled or changed in reaction to physician complaints. Lawsuits brought by the AMA and other physicians groups have also delayed and blocked insurers from adopting what physicians see as unfair ranking, tiering and pay-for-performance programs.

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