Cover Story - June 2008
Tex Med. 2008;104(6):18-23.
By Crystal Conde
Giving patients the most cost-effective and lifesaving preventive treatment that modern medicine offers is becoming increasingly difficult for physicians in private practice. Take San Antonio pediatricians Brandy McCray, MD, FAAP, and Juan Jose Ferreris, MD, FAAP, for example. They face a harsh reality when it comes to vaccinating their young patients.
Drs. Ferreris and McCray are losing money purchasing, administering, and covering the overhead costs associated with immunizations. They are practicing in a health care environment in which vaccine prices soar - especially for new vaccines - while reimbursements from insurance companies plummet. Both physicians and the American Academy of Pediatrics (AAP) fear that, without reform, the current climate will lead to the under-immunization of children and the emergence of vaccine-preventable diseases.
Childhood vaccinations save $10 billion in direct costs and $43 billion in indirect costs each year. According to the American Medical Association, without routine vaccination, direct and indirect costs of childhood preventable diseases would reach $12.3 billion and $46.6 billion, respectively.
Vaccine purchase costs make up more than 50 percent of Dr. McCray's operating expenses for her entire practice. As a solo practitioner, her reimbursement for vaccines does not cover her direct costs of purchasing the vaccine, administering it, and paying for the overhead involved in storing, insuring, taking inventory, paying staff members, and covering waste and nonpayment. In 2007, Dr. McCray lost about $30,000 in direct vaccine costs.
Dr. Ferreris practices in a four-pediatrician group. Vaccine purchase costs account for 40 percent of total overhead expenses in the group's entire practice. In 2007, the group lost about $70,000 in direct vaccine costs.
" For a four-person practice, we're talking about $40,000 a month to buy vaccines. You have $40,000 a month sitting in your refrigerator not gaining interest. It's a lot of money in products out of our pockets waiting to get paid for," Dr. Ferreris said.
To get by financially, both pediatricians have taken drastic measures, including referring some patients to the City of San Antonio Health Department for shots. In addition, Dr. Ferreris and his partners don't purchase or provide newer, more expensive vaccines because of the cost. Dr. McCray offers them because she feels morally obligated to do so.
Despite the less-than-ideal environment, both pediatricians continue to vaccinate. That's not the case in Puerto Rico, where a pediatric vaccine crisis is overwhelming the public health care system. The newspaper Primera Hora reported in February that public health departments are scrambling to vaccinate privately insured patients who are unable to get vaccines from pediatricians. Pediatricians in Puerto Rico say they no longer can provide vaccines because of insurers' inabilities to cover rapidly increasing costs.
Changing the Vaccine Environment
The vaccine reimbursement crisis provides a frightening example of an obstacle that hinders physicians from putting prevention into their practices. Government regulations and administrative burdens, combined with time constraints and increasing pressure from insurance companies to rate quality of care, further encumber physicians' abilities to focus on preventing disease.
Fortunately, the Texas Medical Association, health care organizations, and physicians are working to alleviate hassles and help practitioners improve quality of care and apply preventive measures proven to benefit patients. Online resources are available to help physicians evaluate their practices and improve evidence-based preventive care services. (See " MedBytes .")
Drs. McCray and Ferreris say physicians need to look closely at exactly what they're spending to purchase vaccines, cover overhead costs, and administer the vaccines. AAP has a worksheet [ PDF ] to help physicians calculate the cost involved in vaccinating. The Web site also features the AAP's Pediatric Council Immunization Toolkit, a CD-ROM members can use to initiate discussions with health care payment plans to improve coverage and payments for vaccines and immunization administration.
Both physicians call on their colleagues to support national, state, and local organizations in their advocacy for better vaccine reimbursement, to contact legislators and inform them of the problem, and to make health plans aware of the crisis.
In the meantime, physicians have some recourse in certain areas of reimbursement. The prompt payment law the Texas Legislature passed in 2003 entitles physicians to penalties and interest for late payments from insurance companies. And, the settlements in the federal class action antiracketeering lawsuit against the nation's for-profit HMOs by TMA and other state medical societies and physicians say insurance plans must "pay for the cost of recommended vaccines and injectibles and for administering them." (See " Holding Insurance Companies Accountable .")
Vaccines aren't the only preventive services for which physicians receive little reimbursement. In fact, Partnership for Prevention's report " Why Invest? Recommendations for Improving Your Prevention Investment " [ PDF ] illustrates in what areas of health care employers could be investing more wisely in order to prevent disease among their workers.
For example, lifestyle modification services, such as tobacco cessation services and alcohol problem prevention, rank highly for preventive impact and financial value but are offered by less than 25 percent of employers. Because few insurers reimburse for tobacco cessation counseling and medications, few physicians are paid for the services.
Partnership for Prevention reports that counseling adult patients who smoke saves about $500 per smoker counseled. The organization also reports that in 2005 only 27.5 percent of smokers reported that a health care professional offered them medication assistance to quit smoking or any intervention to quit in a 12-month period.
The report also recognizes influenza vaccinations for their preventive value, yet only 55 percent of employers include them in their primary health care plans. In 2005, about 37 percent of adults 50 and older reported receiving the flu shot in the previous 12 months. Partnership for Prevention estimates that if the percentage of adults receiving the vaccination in that age group increased to 90 percent, 12,000 lives would be saved annually.
Whether physicians care for child or adult patients, they all advocate reimbursement for preventive services. Earl E. Smith III, MD, FACEP, medical director for TMF Health Quality Institute and a former emergency medicine physician in San Antonio, says the U.S. health care system doesn't appreciate the value of preventive care.
"We talk about preventive medicine a lot, and a lot of folks give it lip service. Until we value it enough to pay physicians to focus on prevention, because that's what it takes, we're going to be dealing with these kinds of questions and issues. Right now, the incentives have been taken away," Dr. Smith said.
Eduardo Sanchez, MD, MPH, vice president and medical director of Blue Cross and Blue Shield of Texas, says physicians must strive to reform the reimbursement system. He says better reimbursement for preventive services would help entice physicians to focus on prevention in the practice and in the community.
"Whether it's the federal government or private insurance companies, they need to look at the value of prevention and then begin making the kinds of changes that will encourage physicians and their staffs to do the right thing," the former state health commissioner said.
Transforming the Office Practice
Implementing preventive care measures begins with improving efficiency and quality of care in the medical home. TMA President Josie Williams, MD, says streamlining office workflow is pivotal in helping physicians cope with the demands of doing all that is necessary and needed for providing good preventative care.
She recommends the medical profession consider enlisting the help of social engineers, industrial engineers, or information technology experts who can advise physicians on consolidating some of their work. They could develop management and cost-efficiency measures, as well as technology that might help with all the demands presently required of a physician's office.
The next step involves developing disease registries. These can be created in simple computer spreadsheets or achieved via an electronic medical record (EMR) system. TMA endorses DocSite Registry .
The registry offers resources that help physicians ask the right questions about a patient's medical history, correctly determine which patients require follow-up care, measure the consistency and effectiveness of delivered care, and share patient needs with members of the health care team.
DocSite LLC is the technology partner of the Physicians' Foundation for Health Systems Excellence, created by the antiracketeering lawsuit settlements. For more information on DocSite and to access additional resources and read case studies, visit the TMA Web site .
According to Dr. Williams, disease registries serve an additional purpose.
Insurance companies and government payers continue to measure quality of care based on preventive measures reported through claims-based data. (Read " Worse Than the BCS ," January 2008 Texas Medicine , pages 21-26). When physicians disagree with their ratings and suspect errors on the part of the insurers, Dr. Williams says they must be able to compare the ratings with data they've personally collected for their patient populations.
"If doctors don't build their own databases and don't begin to get their own information, either in aggregate or individually, they're at the mercy of what each insurance company or performance evaluator tells them," she said. "They must start moving in the direction of owning and knowing their patient populations."
TMA is working with Blue Cross and Blue Shield of Texas to make its physician-rating program fair to doctors and useful to patients. Physicians who question their BlueCompare or BlueChoice Solutions ratings should visit www.texmed.org/bluecompare. The site features information about what the ratings mean, how to request a ratings review, improving performance, and TMA advocacy efforts.
The TMA 2007 Electronic Medical Records Survey shows that about 30 percent of participating physicians have adopted an EMR. For physicians who aren't able or prepared to purchase an EMR system, Dr. Williams says the "old-fashioned remedy" for restructuring office workflow is to use a card file. The cards, inserted in a patient's file by date, provide daily reminders of preventive care each patient needs.
The Institute for Healthcare Improvement (IHI) has focused research on fine-tuning doctors' offices so they function at maximum efficiency. Norman Chenven, MD, chief executive officer and founder of Austin Regional Clinic, cochaired IHI's 9th Annual International Summit on Redesigning the Clinical Office Practice in April. He manages a large, multispecialty group, but is aware of the challenges involved in managing a modern family practice.
"The system seems to be proliferating administrative overhead to the point of near insanity," he said. "Something that used to be simple now requires the physician to order it, then justify it, then send the patient somewhere else, then get some report from somewhere else and enter in those charts to know it was done. All of these individual actions may be small, but when you add up the physician time involved in the transaction, it's the opposite of efficient."
Health care experts encouraged conference attendees to move toward electronic prescriptions and medication reconciliation to minimize the opportunity for adverse medication interactions and make the refilling process more efficient. The conference also promoted empowering patients through educational and coaching efforts and the implementation of personal health records (PHRs).
The TMA Health Information Technology site links to SureScripts for information on using electronic prescriptions in the practice and a white paper detailing what physicians need to know about PHRs. The IHI Web site, www.ihi.org, features a Topics section that informs physicians on how to improve; and provides measures, changes, and tools to implement, as well as resources, literature, answers to frequently asked questions, and emerging content on a variety of subjects.
Making Prevention Count
Health care organizations are pooling resources with community groups and medical schools to develop effective preventive interventions to be models for health care delivery. An initiative spearheaded by The University of Texas Southwestern Medical Center/Moncrief Cancer Resources in Fort Worth aims to reduce deaths from breast, prostate, cervical, and colorectal cancers in Tarrant County by promoting and endorsing early cancer screening practices.
Keith E. Argenbright, MD, family physician and medical director at the Fort Worth facility, hopes streamlining cancer screening guidelines from the American Cancer Society and the U.S. Preventive Services Task Force and presenting them in DVD format will improve the rate of clinician recommendations for cancer screenings.
"This is necessary because primary care physicians are on the front lines of cancer prevention and detection. The guidelines are constantly changing and getting more complicated," he said.
Local physicians will be recruited to serve as content experts and communicate the guidelines on the DVD. UT Southwestern/Moncrief Cancer Resources is collaborating with the University of North Texas Health Science Center to distribute the DVDs to all primary care physicians and obstetrician-gynecologists in the Fort Worth area to update them on advanced cancer prevention and detection. More than 700 practitioners will receive the DVD this summer.
A research project will be conducted in conjunction with the North Texas Primary Care Practice-Based Research Network to analyze the impact of the DVD on clinician cancer screening patterns. With permission from a select group of participants, research assistants will perform chart audits.
TMA's Physician Oncology Education Program will work with UT Southwestern/Moncrief Cancer Resources on the project. CME credit will be offered through UT Southwestern. Click here for details.
"We want this to have national implications," Dr. Argenbright said. "We're doing this in a way that the projects we're focusing on have research-quality outcomes that are transferable beyond Tarrant County to the nation."
TMF Health Quality Institute led an initiative to increase lipid testing among diabetic African-American Medicare beneficiaries in the Houston area.
According to the Texas Diabetes Institute, 8 percent, or 12.5 million, non-Hispanic whites in the United States have diabetes. About one-third of the 2.7 million African-Americans with diabetes don't know they have it. The chronic illness is prevalent in 11.4 percent of the African-American adult population, according to the institute.
TMF worked with the American Heart Association, the Greater Houston and Fort Bend County Black Nurses Associations, and other organizations dedicated to decreasing health care disparities among minorities.
The disparity of lipid testing rates between Caucasians and African-Americans at the start of the project was 10.7 percent. At the end, the gap narrowed to 4.8 percent, or a 55 percent decrease overall.
TMF identified the following barriers that affected whether African-American Medicare beneficiaries obtained lipid tests:
- Decreased access to care related to low socioeconomic status and/or lack of health insurance. If the beneficiary hadn't used preventive health benefits because of no insurance in the past, the person would be unlikely to start using the benefits upon turning 65.
- Differences in prevention practice patterns among physicians who predominantly serve African-American patients, compared to those who predominantly serve Caucasian patients.
- Inadequate patient knowledge about diabetes and the need for lipid testing.
- Mistrust of the health care system, specifically government programs such as Medicare.
Joining forces with community health care organizations is an effective way to ensure patients receive preventive care. But knowing which preventive measures to incorporate in a given community or practice can be challenging with so many guidelines out there.
Partnership for Prevention's report " Priorities for America's Health: Capitalizing on Life-Saving, Cost-Effective Preventive Services " ranks 25 recommended preventive services based on its health benefits, in terms of lives saved and lives improved, and on each service's financial value.
Dr. Sanchez says the rankings can help physicians prioritize preventive services in their practices. The report says the following five services have the highest preventive value but are used the least in the medical practice:
- Physicians discussing daily aspirin use with male patients over 40, female patients over 50, and others at risk;
- Screening patients to determine whether they smoke or use other tobacco products, providing brief smoking cessation counseling, and offering therapies and referrals to help them quit;
- Recommending the pneumococcal immunization for older adult patients;
- Screening adults older than 50 regularly for colorectal cancer; and
- Screening sexually active women for chlamydia.
The full report is available on the Partnership for Prevention Web site .
Crystal Conde can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at Crystal Conde .
Holding Insurance Companies Accountable
The prompt payment law that the Texas Medical Association worked so hard to get through the 2003 session of the Texas Legislature requires insurers to pay physicians' claims within certain time frames.
Texas Department of Insurance (TDI) public information officer John Greeley says the law applies to fully insured health plans. Physicians who don't receive reimbursement within the statutory time frames should file a complaint with the department. Complaints can be filed online .
TMA members can also access the Hassle Factor Log. Physicians can get answers to questions about correct coding, claims appeals, prompt pay, and other matters. TMA also can intervene with an insurer or health care payment plan to help resolve a problem.
Call TMA at (800) 880-1300, ext. 1414, or (512) 370-1414, or click here for additional information about the Hassle Factor Log.
Brandy McCray, MD, FAAP, and Juan Jose Ferreris, MD, FAAP, of San Antonio, say it takes about 45 days from the time they file a claim electronically for insurance companies to reimburse them for vaccines.
Under the statute, insurers have 30 days to pay clean electronic claims and 45 days to pay clean paper claims. Failure to do so results in penalties calculated on the difference between a physician's billed charges and the contracted rate.
Penalties are 50 percent of the difference during the first 45 days after the payment deadline and 100 percent of the difference for late payment 46 to 90 days after the deadline. Beyond 90 days of the deadline, insurers are liable for 18 percent annual interest on the unpaid claim.
Mr. Greeley says the department does not intervene in private contract negotiations between providers and carriers, however. Upon being contacted by Dr. Ferreris, the department did facilitate meetings for him and Dr. McCray to discuss general reimbursement concerns with insurance carriers. Mr. Greeley indicates TDI will occasionally help set up such meetings.
If physicians have concerns that insurance companies are failing to comply with the terms of the federal antiracketeering lawsuit settlements, they may file a complaint with a compliance dispute facilitator. Contact information for compliance dispute facilitators is available on the TMA Web site, www.texmed.org/rico , or at www.hmosettlements.com .
"The more documentation, the more evidence physicians from different areas provide, the more information is out there that shows to a third party that insurance companies aren't abiding by RICO or the prompt pay laws," Dr. Ferreris said. "Without a paper trail, in our society, it never happened."
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