MedPAC Proposes Higher Medicare Payments to Physicians
A 2.5-percent increase in Medicare payments to physicians next year has been recommended to Congress by the Medicare Payment Advisory Commission (MedPAC). Currently, physicians are scheduled to receive at least a 1.5-percent increase in 2005.
MedPAC says the increase would maintain patients' access to physician care.
The commission also advised against an increase for skilled nursing facilities and home health services, and urged the health and human services secretary to continue monitoring access to care and the impact on payment selection, and the use of services across post-acute care settings.
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Judge Approves CIGNA Settlement in RICO Case
U.S. Federal Court Judge Federico Moreno has approved a settlement agreement between CIGNA, the Texas Medical Association, and 18 other state and county medical associations in a national class action lawsuit. The plaintiffs allege CIGNA and some of the nation's largest for-profit managed care companies violated contracts and defrauded physicians in violation of the federal Racketeer Influenced and Corrupt Organizations Act (RICO).
Defendants in the case are CIGNA, UnitedHealthcare, Aetna, Coventry, Wellpoint, Humana Health Plan, Inc, PacifiCare Health Systems, Inc., and Anthem Blue Cross Blue Shield.
CIGNA is the second defendant to settle. Aetna and the plaintiffs reached a settlement last May.
The total settlement includes a guaranteed cash payment of $85 million and additional business practice changes of $400 million that will result in hundreds of millions of dollars in real savings to physician practices throughout the country.
Other provisions include establishing a foundation to foster a broad range of public health improvement initiatives and a physician advisory committee to allow physicians to offer input on ways to enhance delivery of health care.
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State Grants Two-Week Delay for Medicaid Preferred Drug List
State officials have agreed to delay implementation of a Preferred Drug List (PDL) for 14 drug classes in the Medicaid program from Feb. 9 until Feb. 23, but rejected a Texas Medical Association request to wait until April to put the PDL into effect. The Texas Health and Human Services Commission (HHSC) will use the additional two weeks to notify high-volume prescribers and pharmacists about the changes and to work with TMA and specialty societies to spread the word about how the PDL and prior authorization process will work.
TMA President Charles W. Bailey Jr., MD, and Lewis Foxhall, MD, chair of the TMA Council on Socioeconomics, had asked HHSC Director Albert Hawkins for the delay. They said they are "concerned about the lack of sufficient time to notify physicians and patients about the PDL and implementation of the prior authorization process." They said in a letter to Mr. Hawkins that "the lack of sufficient physician education about the PDL will only alienate physicians, many of whom will respond by further restricting their Medicaid participation or quitting altogether."
The affected drug classes include ACE inhibitors/calcium channel blockers, analgesics (narcotic), antihistamines, beta blockers, and proton pump inhibitors.
The PDL will expand over the next several months to encompass most of the brand and generic drug classes available to Medicaid patients. A Pharmaceutical and Therapeutics (P&T) Committee, composed of six physicians and five pharmacists, will develop the PDL, and HHSC will grant final approval. Criteria for including a drug on the preferred list include clinical efficacy, safety, and cost. However, the statute enacting the PDL also states that a drug cannot be included if the manufacturer refuses to give a supplemental rebate or other comparable benefit to the state.
Beginning Feb. 23, prescriptions for new or refillable prescriptions of nonpreferred drugs will require prior authorization. For a list of preferred and nonpreferred drugs, click here. Physicians – or their staff – and other prescribers must call (877) 728-3927 to request authorization. Factors considered in approving a nonpreferred drug include previous failure with a preferred agent, allergy, or clinical contraindication. If granted, prior authorization is valid for one year. A pharmacist may dispense a 72-hour emergency supply of a nonpreferred drug in cases where prior authorization is pending. (For a detailed description of the prior authorization process, click here.)
TMA continues to meet regularly with HHSC to press its concerns about the haste of implementation and emerging quality-of-care issues. Pediatricians have raised concerns about the lack of preferred drugs available for infants, while the Texas Society of Psychiatric Physicians, backed by TMA, is asking the state to reconsider a recent decision by the P&T committee to exclude from the preferred list a commonly prescribed agent for schizophrenia.
"TMA understands the state's imperative to reduce prescription drug costs. Reducing expenditures, however, must not be at the expense of jeopardizing good patient care or the stability of the physician network," said John Holcomb, MD, chair of TMA's Ad Hoc Committee on Medicaid.
For a list of frequently asked questions about the PDL and prior authorization process, visit the TMA Web site.
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TMA Supports Patients' Right to Appeal HMO Denials
A patient's right to appeal an HMO's decision denying medical care in two cases now before the U.S. Supreme Court is being supported by the nation's largest medical society. The Texas Medical Association, along with the American Medical Association and the American Psychiatric Association, have filed a friend-of-the-court brief (PDF) supporting patients in their lawsuits against Aetna Health Inc. and CIGNA Healthcare of Texas.
One lawsuit tests whether a health plan can mandate a certain drug, despite side effects and against the physician's best judgment. The other tests a health plan's determination of medical necessity for a hospital stay, again against the physician's best judgment. Both patients filed the cases under the Texas Health Care Liability Act.
The 5th U.S. Circuit Court of Appeals remanded the cases to state court, and the health plans are appealing that decision to the U.S. Supreme Court. Aetna and CIGNA want the cases heard in federal court.
"The issue is whether insurers can hide behind federal ERISA rules in an attempt to deny timely, adequate patient care and without accountability as mandated by the State of Texas," said Donald P. Wilcox, JD, TMA general counsel. ERISA, or the Employee Retirement Income Security Act of 1974, protects private employee pension plans from fraud and mismanagement.
Texas passed the Texas Health Care Liability Act in 1997, the first-in-the-nation law guaranteeing patients the right to sue a health plan for negligent medical-necessity decisions. These decisions can counter the best judgment of the treating physician and cause harm to the patient.
"Logic at the time ERISA passed was that it adds costs when multistate health plans have to meet the regulatory requirements of all the states in which they operate," Mr. Wilcox said. "A single federal law made sense. But in this instance, we contend ERISA has no bearing. Once an individual has been accepted into a health plan, he or she then becomes a patient. ERISA continues to regulate the individual's status as a 'participant' in the employee benefit plan, but ERISA does not preempt state law if the health plan's actions equate to negligent diagnosis or treatment."
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“Lick and Stick” Scheme Costs Drug Companies
Texas has received $9 million as its share of a $22 million state/federal Medicaid fraud settlement with pharmaceutical giants Bayer Corp. and GlaxoSmithKline.
Texas Attorney General Greg Abbott said the money represents actual losses to the Texas' Medicaid program, plus penalties. The federal government also received settlement payments for federal Medicaid funds spent fraudulently. Forty-eight other states and the District of Columbia also participated in the settlements, thought to be the largest ever among Medicaid fraud cases involving pharmaceutical manufacturers.
The restitution is the result of a lengthy multistate investigation into the companies' failure to report their "best price" to the federal Centers for Medicare & Medicaid Services (CMS) for four drugs – Paxil and Flonase, made by GlaxoSmithKline, and Cipro and Adalat CC, made by Bayer.
For certain drugs to qualify for Medicaid payment, all manufacturers must provide "best price" information, the lowest price at which a manufacturer offers the drugs for sale to commercial purchasers. CMS uses the information to calculate rebates to state Medicaid programs.
The fraud complaints allege that Bayer and GlaxoSmithKline failed to pay sufficient rebates to state Medicaid programs nationwide in connection with the private labeling of these four drugs, as required by the federal Medicaid drug rebate statutes.
The companies sold the products to HMOs at sharply discounted prices, then concealed and avoided their obligation to pay additional rebates to the states' Medicaid programs by relabeling or repackaging these drugs under the HMOs' private labels, the attorney general said. This scheme is known in the industry as "lick and stick."
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TMA Takes Workers' Comp Case to Higher Court
Failure of the Texas workers' compensation program to provide prompt, quality medical care to injured workers has prompted the Texas Medical Association to ask the 3rd Court of Appeals to help rectify the situation.
"The Texas Workers' Compensation Commission [TWCC] is bound by state law to base medical fees on Texas data, on the Texas experience," said TMA General Counsel Donald P. Wilcox, JD. "TWCC has a responsibility to assure quality medical care to Texas workers, a responsibility they ignored and punted to the federal government."
TMA successfully sought an injunction against TWCC in the summer of 2002 to stop implementation of arbitrary rates based solely on a TWCC employee's "best business judgment." The judge gave TWCC an opportunity to develop acceptable rationale for the rate. TWCC created a rationale for its rates without holding public hearings or consulting its own medical advisory committee.
"Texas workers are struggling to get timely, quality medical care through the state's program," said TMA President Charles W. Bailey Jr., MD. "The exceedingly difficult process of getting reimbursed for even emergency care, plus the inadequate reimbursement rate, has driven doctors out of the system."
According to TWCC's own statistics, fewer than half of the participating physicians still remain in the system. "Many of the doctors who do participate do so only because they are on call at their local hospitals for emergency case," Dr. Bailey said.
TMA is working with elected officials to restore the state's workers' compensation program to its intended purpose. The legal appeal is just one avenue in TMA's ongoing efforts to create a system that meets the needs of injured workers, employers, and the medical community.
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Winter Conference to Feature Prompt Pay, TSBME, Strategic Planning
A luncheon speech by the governor and discussions about prompt pay, the Texas State Board of Medical Examiners (TSBME), and the impact of changing patient demographics on medical practices are on tap for the 2004 TMA Winter Conference on Saturday, Feb. 28, at the Renaissance Austin Hotel. Conference participants also get a chance to take part in a strategic planning session.
Scheduled speakers and their topics include:
- Gov. Rick Perry: leading the way to a healthier Texas;
- Insurance Commissioner José Montemayor: assuring patient access and prompt payment through effective laws and regulations;
- TSBME President Lee Anderson, MD: issues and challenges the board faces, including the legislature's sunset review process;
- State Rep. Vicki Truitt: supporting quality medical care with sound legislation;
- First Lady Anita Perry and Texas Health Commissioner Eduardo Sanchez, MD: protecting children through immunization;
- Philadelphia attorney Alice Gosfield, JD: the doctor-patient relationship as the business case for quality; and
- Richard Cooper, MD: changing demographic trends and how they affect physicians' practices.
The conference begins at 7:30 a.m. with a dawn-duster session on the medical staff's role in improving patient care. The general session begins at 9 a.m. The Texas Medical Association Insurance Trust will host a luncheon at 12:30 p.m.
That afternoon, TMA's biennial strategic planning meeting will be held from 2:15 to 5 p.m. Participants will help shape association strategies for the next two years. All physicians attending the conference are invited, and members of TMA councils, committees, and boards are encouraged to participate.
In addition to the Saturday activities, a conference reception on Friday, from 5:30 to 6:45 pm, will be hosted by Blue Cross and Blue Shield of Texas.
The conference is free for all TMA members and you can earn continuing medical education credit by attending. You can register for the conference on theTMA Web site.
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Free TMA Newsletter Offers Practice Management Tips
Want free help with juggling the demands of your practice? Then sign up now to receive TMA Practice e-tips, a semimonthly electronic newsletter that offers brief, practical tips for managing a medical practice in Texas.
Each edition provides hands-on, use-it-now advice on coding, billing, reimbursement, HIPAA compliance, office policies and procedures, practice marketing, and much more, along with useful links for additional information.
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When You Need Help Hiring the Right Person for Your Practice
Hiring the right people is critical to the success of your practice, as management and staff are one of your biggest expenses, and turnover is both disruptive and costly. Attracting good candidates and evaluating them wisely can be more difficult than you think, however.
For example, TMA Physician Services consultants suggest that in addition to the facts on a résumé, you should consider the intangible qualities that make a candidate a good "fit" for your practice culture. Does the candidate project a winning attitude? Does he exhibit good communication skills? Does she have a professional appearance?
Hiring right is not a matter of chance. The following steps, essential to successful hiring, require careful preparation, judgment, and follow-up:
- Define your needs (for example, what type of management works best for your practice).
- Write a job description summarizing the duties and responsibilities of the position.
- Research competitive salary and benefits packages for your area.
- Write and place recruitment ads in appropriate publications and on appropriate Web sites.
- Know the legal requirements for interviewing and hiring.
- Develop a list of interview questions. Ask questions that provide insight into how the candidate thinks and works.
- Test candidates as applicable (for example, coding skills).
- Be consistent throughout the interview process.
- Check references and conduct a background check before you make an offer.
Recruiting a good employee can be a time-consuming and laborious process. That's why TMA Physician Services offers management and staff recruiting services. A consultant can help you define your needs; recruit, screen, and recommend candidates for you; and even schedule and participate in the interviews.
For more information, call (800) 523-8776 or log on to www.consulting.texmed.org.
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Hit the High Notes
The personal and professional triumphs of Irish tenor Ronan Tynan, MD, will fill the air at the opening general session of TexMed 2004, TMA's annual meeting. Dr. Tynan will present "Hitting the High Notes: Living Life to the Fullest" on Thursday, May 13, from 3:30 to 4:30 p.m. at the Austin Convention Center.
His presentation is sponsored by the Texas Medical Liability Trust (TMLT). Immediately following the general session, TMLT will celebrate its 25th anniversary with a wine-and-cheese reception, where Dr. Tynan will be available to sign copies of his new biography, Halfway Home: My Life ’Til Now.
Join TMA and your colleagues for these two events.
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TMA Seminars
Practice Management, Ext. 1421
Medicare Update
2/10 San Antonio
2/11 Corpus Christi
2/17 Amarillo
2/18 Lubbock
2/24 Tyler
2/25 Dallas
Defensive Documentation
2/24 Austin
2/25 Dallas
2/26 Fort Worth
3/4 San Antonio
3/10 Houston
Impairment Evaluation under Texas Workers' Compensation
3/5-6 Houston
Physician Health and Rehabilitation, Ext. 1342
Appropriate Management of Chronic Pain
4/6 Paris
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