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Nuanced approach works best for potential ECT patients
Las Vegas – Electroconvulsive therapy is useful for many patients, particularly those with more severe depressive symptoms and more treatment resistance, according to Dr. Bruce J. Cohen.
However, a survey of 116 psychiatrists in Virginia shows that clinician experience with electroconvulsive therapy (ECT) varies widely. In fact, 8% of respondents reported having no experience with ECT, 41% observed it in residency, 38% performed it while supervised in residency, 35% had performed ECT but are not currently using it, and only 11% indicated that they currently perform ECT (J ECT. 2011;27[3]:232-5). “While most psychiatrists had a basic understanding of ECT and favorable attitude, a lesser fund of knowledge about ECT was associated with both a less favorable attitude toward ECT and fewer referrals,” Dr. Cohen, one of the study authors, said at the annual psychopharmacology update held by the Nevada Psychiatric Association. “Those who viewed ECT as a treatment of last resort made fewer referrals.”
Dr. Cohen of the department of psychiatry and neurobehavioral sciences at the University of Virginia, Charlottesville, said the most common indications for ECT are major depressive episodes both in unipolar and bipolar disorders, including medication-resistant depression; manic or mixed states; inability to tolerate medication side effects; and the need for more rapid and/or certain response.
“You might have a situation with an inpatient where the acuity of the depression is so high that you move to ECT almost immediately,” he said. Other indications include a previous good response to ECT, catatonia, refractory schizophrenia, more severe mood disorder in pregnancy, and neuroleptic malignant syndrome.
Before he meets with patients to discuss ECT, Dr. Cohen said he determines whether the focus will be on prescreening for ECT or a broader consultation about treatment-resistant depression in which he and the patient explore other treatment options besides ECT. “That’s the approach that I favor, because a patient might decide after talking to me that they don’t want ECT, or they might say, ‘I’m glad I talked to you, but I’m not quite ready for ECT at this point,’ ” he said.
Other factors could be contributing to the patient’s current depressive state, he said, perhaps someone “who’s on a very high dose of lithium that’s causing fatigue and apathy or cognitive disturbance. Or maybe the patient has had treatment-resistant psychosis, and the more you talk to them, the more you realize it may be obsessive-compulsive disorder, and not psychotic depression at all, and they’ve tried treatment with various antipsychotic agents but never with a higher dose of [a selective serotonin reuptake inhibitor].”
During the consultation, he said he emphasizes that ECT is not effective for all patients. “This is important, because some patients will come in and say, ‘ECT is my last hope,’ he said. “They might have already decided that if they don’t respond to ECT, they’re going to kill themselves. I share anecdotes and let them know that even if they end up not responding to ECT, there are other treatments out there, and not all treatments have been exhausted.” He also discusses options should ECT be successful for the patient, including the potential for maintenance therapy with ECT or a medication regimen.
Having a family member or a friend accompany the patient to the consultation is helpful. “These are the people who may bring them back and forth to treatments,” he said. “These are also the people who could sabotage treatment. If they don’t know what to expect in terms of transient confusion or memory problems or even coming out of the treatment room looking flushed, you could see where a family member or friend might be frightened. So the family member can be your best ally.”
There are no absolute medical contraindications to ECT, Dr. Cohen said, but medical conditions to be stabilized include cardiac pacemakers, hypertension, pulmonary disease, cardiovascular disease, liver disease, diabetes, skull defects, pregnancy, and CNS conditions that increase the risk of delirium, including dementia, stroke, head injury, Parkinson’s disease, and multiple sclerosis. “Sometimes we’re asking for clearance on a person who has a brain aneurysm,” he said. “I want to get a detailed medical history. At our facility, usually anesthesia will consult with the patient shortly before the treatment rather than as a whole separate outpatient visit.”
Labs to consider prior to performing ECT will include an EKG, blood count, chemistry panel, chest X-ray, spine films, and neuroimaging, “but those things aren’t obligatory or required,” he said. “But just like in any case of refractory depression, you’d want to order those things as appropriate.”
Prior to ECT, Dr. Cohen said he considers discontinuing or minimizing medications that have anticonvulsant effects, such as carbamazepine and lamotrigine and benzodiazepines. “On the other hand, you don’t want the patient relapsing right as you’re starting your treatment, so it might be that you can’t get them off benzodiazepines completely,” he said.
According to a recent meta-analysis of 32 studies, the most robust predictors of poor response to ECT were longer depressive episode duration and medication resistance, while age, psychosis, and melancholic features were not found to be as clinically useful (J Clin Psychiatry. 2015;76[10]:1374-84). Dr. Cohen noted that a major consideration during a pre-ECT consultation is working out any potential logistical difficulties in advance. For example, during an acute course of ECT, he said he advises patients not to drive, even on nontreatment days.
“If you live in a city with good public transportation, it may not be a big deal, but it can be difficult in more rural areas,” he said. “It’s not that ECT makes you lose the memory of how to drive a car, but could give you subtle cognitive slowing or decreased reaction times. Therefore, arranging to have an adequate support system throughout the course of ECT is essential.”
Dr. Cohen reported having no relevant financial conflicts.
Las Vegas – Electroconvulsive therapy is useful for many patients, particularly those with more severe depressive symptoms and more treatment resistance, according to Dr. Bruce J. Cohen.
However, a survey of 116 psychiatrists in Virginia shows that clinician experience with electroconvulsive therapy (ECT) varies widely. In fact, 8% of respondents reported having no experience with ECT, 41% observed it in residency, 38% performed it while supervised in residency, 35% had performed ECT but are not currently using it, and only 11% indicated that they currently perform ECT (J ECT. 2011;27[3]:232-5). “While most psychiatrists had a basic understanding of ECT and favorable attitude, a lesser fund of knowledge about ECT was associated with both a less favorable attitude toward ECT and fewer referrals,” Dr. Cohen, one of the study authors, said at the annual psychopharmacology update held by the Nevada Psychiatric Association. “Those who viewed ECT as a treatment of last resort made fewer referrals.”
Dr. Cohen of the department of psychiatry and neurobehavioral sciences at the University of Virginia, Charlottesville, said the most common indications for ECT are major depressive episodes both in unipolar and bipolar disorders, including medication-resistant depression; manic or mixed states; inability to tolerate medication side effects; and the need for more rapid and/or certain response.
“You might have a situation with an inpatient where the acuity of the depression is so high that you move to ECT almost immediately,” he said. Other indications include a previous good response to ECT, catatonia, refractory schizophrenia, more severe mood disorder in pregnancy, and neuroleptic malignant syndrome.
Before he meets with patients to discuss ECT, Dr. Cohen said he determines whether the focus will be on prescreening for ECT or a broader consultation about treatment-resistant depression in which he and the patient explore other treatment options besides ECT. “That’s the approach that I favor, because a patient might decide after talking to me that they don’t want ECT, or they might say, ‘I’m glad I talked to you, but I’m not quite ready for ECT at this point,’ ” he said.
Other factors could be contributing to the patient’s current depressive state, he said, perhaps someone “who’s on a very high dose of lithium that’s causing fatigue and apathy or cognitive disturbance. Or maybe the patient has had treatment-resistant psychosis, and the more you talk to them, the more you realize it may be obsessive-compulsive disorder, and not psychotic depression at all, and they’ve tried treatment with various antipsychotic agents but never with a higher dose of [a selective serotonin reuptake inhibitor].”
During the consultation, he said he emphasizes that ECT is not effective for all patients. “This is important, because some patients will come in and say, ‘ECT is my last hope,’ he said. “They might have already decided that if they don’t respond to ECT, they’re going to kill themselves. I share anecdotes and let them know that even if they end up not responding to ECT, there are other treatments out there, and not all treatments have been exhausted.” He also discusses options should ECT be successful for the patient, including the potential for maintenance therapy with ECT or a medication regimen.
Having a family member or a friend accompany the patient to the consultation is helpful. “These are the people who may bring them back and forth to treatments,” he said. “These are also the people who could sabotage treatment. If they don’t know what to expect in terms of transient confusion or memory problems or even coming out of the treatment room looking flushed, you could see where a family member or friend might be frightened. So the family member can be your best ally.”
There are no absolute medical contraindications to ECT, Dr. Cohen said, but medical conditions to be stabilized include cardiac pacemakers, hypertension, pulmonary disease, cardiovascular disease, liver disease, diabetes, skull defects, pregnancy, and CNS conditions that increase the risk of delirium, including dementia, stroke, head injury, Parkinson’s disease, and multiple sclerosis. “Sometimes we’re asking for clearance on a person who has a brain aneurysm,” he said. “I want to get a detailed medical history. At our facility, usually anesthesia will consult with the patient shortly before the treatment rather than as a whole separate outpatient visit.”
Labs to consider prior to performing ECT will include an EKG, blood count, chemistry panel, chest X-ray, spine films, and neuroimaging, “but those things aren’t obligatory or required,” he said. “But just like in any case of refractory depression, you’d want to order those things as appropriate.”
Prior to ECT, Dr. Cohen said he considers discontinuing or minimizing medications that have anticonvulsant effects, such as carbamazepine and lamotrigine and benzodiazepines. “On the other hand, you don’t want the patient relapsing right as you’re starting your treatment, so it might be that you can’t get them off benzodiazepines completely,” he said.
According to a recent meta-analysis of 32 studies, the most robust predictors of poor response to ECT were longer depressive episode duration and medication resistance, while age, psychosis, and melancholic features were not found to be as clinically useful (J Clin Psychiatry. 2015;76[10]:1374-84). Dr. Cohen noted that a major consideration during a pre-ECT consultation is working out any potential logistical difficulties in advance. For example, during an acute course of ECT, he said he advises patients not to drive, even on nontreatment days.
“If you live in a city with good public transportation, it may not be a big deal, but it can be difficult in more rural areas,” he said. “It’s not that ECT makes you lose the memory of how to drive a car, but could give you subtle cognitive slowing or decreased reaction times. Therefore, arranging to have an adequate support system throughout the course of ECT is essential.”
Dr. Cohen reported having no relevant financial conflicts.
Las Vegas – Electroconvulsive therapy is useful for many patients, particularly those with more severe depressive symptoms and more treatment resistance, according to Dr. Bruce J. Cohen.
However, a survey of 116 psychiatrists in Virginia shows that clinician experience with electroconvulsive therapy (ECT) varies widely. In fact, 8% of respondents reported having no experience with ECT, 41% observed it in residency, 38% performed it while supervised in residency, 35% had performed ECT but are not currently using it, and only 11% indicated that they currently perform ECT (J ECT. 2011;27[3]:232-5). “While most psychiatrists had a basic understanding of ECT and favorable attitude, a lesser fund of knowledge about ECT was associated with both a less favorable attitude toward ECT and fewer referrals,” Dr. Cohen, one of the study authors, said at the annual psychopharmacology update held by the Nevada Psychiatric Association. “Those who viewed ECT as a treatment of last resort made fewer referrals.”
Dr. Cohen of the department of psychiatry and neurobehavioral sciences at the University of Virginia, Charlottesville, said the most common indications for ECT are major depressive episodes both in unipolar and bipolar disorders, including medication-resistant depression; manic or mixed states; inability to tolerate medication side effects; and the need for more rapid and/or certain response.
“You might have a situation with an inpatient where the acuity of the depression is so high that you move to ECT almost immediately,” he said. Other indications include a previous good response to ECT, catatonia, refractory schizophrenia, more severe mood disorder in pregnancy, and neuroleptic malignant syndrome.
Before he meets with patients to discuss ECT, Dr. Cohen said he determines whether the focus will be on prescreening for ECT or a broader consultation about treatment-resistant depression in which he and the patient explore other treatment options besides ECT. “That’s the approach that I favor, because a patient might decide after talking to me that they don’t want ECT, or they might say, ‘I’m glad I talked to you, but I’m not quite ready for ECT at this point,’ ” he said.
Other factors could be contributing to the patient’s current depressive state, he said, perhaps someone “who’s on a very high dose of lithium that’s causing fatigue and apathy or cognitive disturbance. Or maybe the patient has had treatment-resistant psychosis, and the more you talk to them, the more you realize it may be obsessive-compulsive disorder, and not psychotic depression at all, and they’ve tried treatment with various antipsychotic agents but never with a higher dose of [a selective serotonin reuptake inhibitor].”
During the consultation, he said he emphasizes that ECT is not effective for all patients. “This is important, because some patients will come in and say, ‘ECT is my last hope,’ he said. “They might have already decided that if they don’t respond to ECT, they’re going to kill themselves. I share anecdotes and let them know that even if they end up not responding to ECT, there are other treatments out there, and not all treatments have been exhausted.” He also discusses options should ECT be successful for the patient, including the potential for maintenance therapy with ECT or a medication regimen.
Having a family member or a friend accompany the patient to the consultation is helpful. “These are the people who may bring them back and forth to treatments,” he said. “These are also the people who could sabotage treatment. If they don’t know what to expect in terms of transient confusion or memory problems or even coming out of the treatment room looking flushed, you could see where a family member or friend might be frightened. So the family member can be your best ally.”
There are no absolute medical contraindications to ECT, Dr. Cohen said, but medical conditions to be stabilized include cardiac pacemakers, hypertension, pulmonary disease, cardiovascular disease, liver disease, diabetes, skull defects, pregnancy, and CNS conditions that increase the risk of delirium, including dementia, stroke, head injury, Parkinson’s disease, and multiple sclerosis. “Sometimes we’re asking for clearance on a person who has a brain aneurysm,” he said. “I want to get a detailed medical history. At our facility, usually anesthesia will consult with the patient shortly before the treatment rather than as a whole separate outpatient visit.”
Labs to consider prior to performing ECT will include an EKG, blood count, chemistry panel, chest X-ray, spine films, and neuroimaging, “but those things aren’t obligatory or required,” he said. “But just like in any case of refractory depression, you’d want to order those things as appropriate.”
Prior to ECT, Dr. Cohen said he considers discontinuing or minimizing medications that have anticonvulsant effects, such as carbamazepine and lamotrigine and benzodiazepines. “On the other hand, you don’t want the patient relapsing right as you’re starting your treatment, so it might be that you can’t get them off benzodiazepines completely,” he said.
According to a recent meta-analysis of 32 studies, the most robust predictors of poor response to ECT were longer depressive episode duration and medication resistance, while age, psychosis, and melancholic features were not found to be as clinically useful (J Clin Psychiatry. 2015;76[10]:1374-84). Dr. Cohen noted that a major consideration during a pre-ECT consultation is working out any potential logistical difficulties in advance. For example, during an acute course of ECT, he said he advises patients not to drive, even on nontreatment days.
“If you live in a city with good public transportation, it may not be a big deal, but it can be difficult in more rural areas,” he said. “It’s not that ECT makes you lose the memory of how to drive a car, but could give you subtle cognitive slowing or decreased reaction times. Therefore, arranging to have an adequate support system throughout the course of ECT is essential.”
Dr. Cohen reported having no relevant financial conflicts.
EXPERT ANALYSIS AT THE NPA PSYCHOPHARMACOLOGY UPDATE
5 Tips to Finding a Good Locum Tenens Company
Over the past five years, I have worked as a locum tenens hospitalist with more than 12 different locum tenens companies. I have learned a lot through this process. At one point, I even considered starting my own locum tenens company because of the frustrations I was feeling about the inefficiencies of many of these companies. I would like to help those of you either already practicing as a locum tenens physician or considering practicing through this process to make it as painless as possible.
Here are my tips to be aware of when choosing a locum tenens company to work with.
- Bigger isn’t necessarily better. There are a few companies that advertise a lot. I’m sure you are all very well aware of them. They send out many emails, call numerous times, and somehow have a banner on every website you visit. These companies tend to have large overhead costs. These costs mean that your hourly rate may be lower. Smaller companies are sometimes less efficient, but as long as you make sure your expectations are heard, they will often give you a rate that the bigger companies cannot afford.
- State your terms. As physicians, we are often not the most business savvy. Remember that locum tenens companies exist because there is a shortage of hospitalists in some areas. We need to be able to state certain terms; if you don’t like something, then make sure you add that into your contract. For example, patient safety should always come first; make sure you establish a cap for the number of patients you are willing to see per day.
- Be protective of your CV. Remember that locum tenens companies profit when you work, so they will want to hand out your CV to as many hospitals as possible. While they make it sound like it is in your best interest, it may not be. If a company presents you to a hospital, most of the time the contract you sign with them states that they “own” your presentation for two years. This means that if you do not like the locum tenens company or if another company is offering you more for the same hospital, you have to work with the company that presented you first. Make sure you have a written agreement between you and your locum tenens company with regard to presentations stating which hospitals the locum tenens company can present you to, with a follow-up response from the locum tenens company stating when they presented you.
- Your recruiter is your best advocate. Make sure you get along. Make sure you have very good communication with your recruiter, who is the one who will be doing all of your scheduling and negotiating. If you do not have a good relationship, move on to a new recruiter or to a new company.
- Have fun! Working as a locum tenens physician, in my opinion, is the best of everything combined. There are very few jobs where you can decide when you want to work, dictate your terms, and get paid well doing something you love. Locum tenens takes a little bit of getting used to; when you have it figured out, it is empowering and enjoyable. TH
Geeta Arora, MD, is board certified in internal medicine and integrative holistic medicine.
Over the past five years, I have worked as a locum tenens hospitalist with more than 12 different locum tenens companies. I have learned a lot through this process. At one point, I even considered starting my own locum tenens company because of the frustrations I was feeling about the inefficiencies of many of these companies. I would like to help those of you either already practicing as a locum tenens physician or considering practicing through this process to make it as painless as possible.
Here are my tips to be aware of when choosing a locum tenens company to work with.
- Bigger isn’t necessarily better. There are a few companies that advertise a lot. I’m sure you are all very well aware of them. They send out many emails, call numerous times, and somehow have a banner on every website you visit. These companies tend to have large overhead costs. These costs mean that your hourly rate may be lower. Smaller companies are sometimes less efficient, but as long as you make sure your expectations are heard, they will often give you a rate that the bigger companies cannot afford.
- State your terms. As physicians, we are often not the most business savvy. Remember that locum tenens companies exist because there is a shortage of hospitalists in some areas. We need to be able to state certain terms; if you don’t like something, then make sure you add that into your contract. For example, patient safety should always come first; make sure you establish a cap for the number of patients you are willing to see per day.
- Be protective of your CV. Remember that locum tenens companies profit when you work, so they will want to hand out your CV to as many hospitals as possible. While they make it sound like it is in your best interest, it may not be. If a company presents you to a hospital, most of the time the contract you sign with them states that they “own” your presentation for two years. This means that if you do not like the locum tenens company or if another company is offering you more for the same hospital, you have to work with the company that presented you first. Make sure you have a written agreement between you and your locum tenens company with regard to presentations stating which hospitals the locum tenens company can present you to, with a follow-up response from the locum tenens company stating when they presented you.
- Your recruiter is your best advocate. Make sure you get along. Make sure you have very good communication with your recruiter, who is the one who will be doing all of your scheduling and negotiating. If you do not have a good relationship, move on to a new recruiter or to a new company.
- Have fun! Working as a locum tenens physician, in my opinion, is the best of everything combined. There are very few jobs where you can decide when you want to work, dictate your terms, and get paid well doing something you love. Locum tenens takes a little bit of getting used to; when you have it figured out, it is empowering and enjoyable. TH
Geeta Arora, MD, is board certified in internal medicine and integrative holistic medicine.
Over the past five years, I have worked as a locum tenens hospitalist with more than 12 different locum tenens companies. I have learned a lot through this process. At one point, I even considered starting my own locum tenens company because of the frustrations I was feeling about the inefficiencies of many of these companies. I would like to help those of you either already practicing as a locum tenens physician or considering practicing through this process to make it as painless as possible.
Here are my tips to be aware of when choosing a locum tenens company to work with.
- Bigger isn’t necessarily better. There are a few companies that advertise a lot. I’m sure you are all very well aware of them. They send out many emails, call numerous times, and somehow have a banner on every website you visit. These companies tend to have large overhead costs. These costs mean that your hourly rate may be lower. Smaller companies are sometimes less efficient, but as long as you make sure your expectations are heard, they will often give you a rate that the bigger companies cannot afford.
- State your terms. As physicians, we are often not the most business savvy. Remember that locum tenens companies exist because there is a shortage of hospitalists in some areas. We need to be able to state certain terms; if you don’t like something, then make sure you add that into your contract. For example, patient safety should always come first; make sure you establish a cap for the number of patients you are willing to see per day.
- Be protective of your CV. Remember that locum tenens companies profit when you work, so they will want to hand out your CV to as many hospitals as possible. While they make it sound like it is in your best interest, it may not be. If a company presents you to a hospital, most of the time the contract you sign with them states that they “own” your presentation for two years. This means that if you do not like the locum tenens company or if another company is offering you more for the same hospital, you have to work with the company that presented you first. Make sure you have a written agreement between you and your locum tenens company with regard to presentations stating which hospitals the locum tenens company can present you to, with a follow-up response from the locum tenens company stating when they presented you.
- Your recruiter is your best advocate. Make sure you get along. Make sure you have very good communication with your recruiter, who is the one who will be doing all of your scheduling and negotiating. If you do not have a good relationship, move on to a new recruiter or to a new company.
- Have fun! Working as a locum tenens physician, in my opinion, is the best of everything combined. There are very few jobs where you can decide when you want to work, dictate your terms, and get paid well doing something you love. Locum tenens takes a little bit of getting used to; when you have it figured out, it is empowering and enjoyable. TH
Geeta Arora, MD, is board certified in internal medicine and integrative holistic medicine.
Damage to nearby structure common cause of hernia malpractice claim
JACKSONVILLE, FLA. – General surgeons are among the most sued physicians, and hernia repair is one of the most common operations they perform, so a study was conducted to drill down into the legal data on hernia repair to determine what about the operation is most likely to get surgeons in trouble.
They found that a failure to diagnose a complication caused by damage to a nearby structure during the operation was the most common cause for a malpractice suit for hernia repair, Dr. Nadeem Haddad of the Mayo Clinic in Rochester, Minn., reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Hernia repair with more than 1 million cases annually is one of the most common surgical procedures,” Dr. Haddad said. “The most common type of operation for malpractice was inguinal hernia repair. The majority of cases were elective cases where the informed consent was not breached.”
The researchers sampled data on 250 malpractice cases arising from hernia surgery filed with the Westlaw Next legal database between 1985 and 2015, Dr. Haddad said. He added that the sample is not inclusive of all malpractice cases related to hernia repair in that time. “Our objective was to analyze reasons for litigation related to hernia repairs,” he said.
Among the hernia cases from the database, physicians (defendants) won 59%, patients (plaintiffs) won around 27%, and the remainder went to settlement before a verdict. Award payments ranged from $10,000 for a case where a Penrose drain was left in the patient to $16 million in the case of death of an infant due to perioperative hyperkalemia.
Eighty-four percent of the cases in the study involved inguinal or ventral hernia repair, Dr. Haddad said, but the Westlaw Next database did not differentiate between the two types of procedures. Nor did it separate out pediatric or adult repairs. Westlaw Next provides the alleged reason for litigation and gives details about lawsuits. The researchers classified the alleged reasons for the lawsuits based on the time period in which they happened: preoperatively, intraoperatively, and postoperatively.
“The single most common reason for malpractice in hernia repair was failure to diagnose a complication following damage to a surrounding structure,” Dr. Haddad said.
The state of New York had the highest number of medical malpractice cases (46), followed closely by California (42). In 15% of cases (38) the patients claimed a breach of informed consent by the surgeon
“While understanding the reasons why surgeons go to trial, the risk of future lawsuits may lessen if measures are enacted to prevent such outcomes,” Dr. Haddad said. “Following protocols in diagnosis and management, attention to good surgical technique, and keeping a checklist of possible complications are some of the ways to improve patients safety and decrease chances of litigation.”
Dr. Haddad and coauthors had no financial relationships to disclose.
JACKSONVILLE, FLA. – General surgeons are among the most sued physicians, and hernia repair is one of the most common operations they perform, so a study was conducted to drill down into the legal data on hernia repair to determine what about the operation is most likely to get surgeons in trouble.
They found that a failure to diagnose a complication caused by damage to a nearby structure during the operation was the most common cause for a malpractice suit for hernia repair, Dr. Nadeem Haddad of the Mayo Clinic in Rochester, Minn., reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Hernia repair with more than 1 million cases annually is one of the most common surgical procedures,” Dr. Haddad said. “The most common type of operation for malpractice was inguinal hernia repair. The majority of cases were elective cases where the informed consent was not breached.”
The researchers sampled data on 250 malpractice cases arising from hernia surgery filed with the Westlaw Next legal database between 1985 and 2015, Dr. Haddad said. He added that the sample is not inclusive of all malpractice cases related to hernia repair in that time. “Our objective was to analyze reasons for litigation related to hernia repairs,” he said.
Among the hernia cases from the database, physicians (defendants) won 59%, patients (plaintiffs) won around 27%, and the remainder went to settlement before a verdict. Award payments ranged from $10,000 for a case where a Penrose drain was left in the patient to $16 million in the case of death of an infant due to perioperative hyperkalemia.
Eighty-four percent of the cases in the study involved inguinal or ventral hernia repair, Dr. Haddad said, but the Westlaw Next database did not differentiate between the two types of procedures. Nor did it separate out pediatric or adult repairs. Westlaw Next provides the alleged reason for litigation and gives details about lawsuits. The researchers classified the alleged reasons for the lawsuits based on the time period in which they happened: preoperatively, intraoperatively, and postoperatively.
“The single most common reason for malpractice in hernia repair was failure to diagnose a complication following damage to a surrounding structure,” Dr. Haddad said.
The state of New York had the highest number of medical malpractice cases (46), followed closely by California (42). In 15% of cases (38) the patients claimed a breach of informed consent by the surgeon
“While understanding the reasons why surgeons go to trial, the risk of future lawsuits may lessen if measures are enacted to prevent such outcomes,” Dr. Haddad said. “Following protocols in diagnosis and management, attention to good surgical technique, and keeping a checklist of possible complications are some of the ways to improve patients safety and decrease chances of litigation.”
Dr. Haddad and coauthors had no financial relationships to disclose.
JACKSONVILLE, FLA. – General surgeons are among the most sued physicians, and hernia repair is one of the most common operations they perform, so a study was conducted to drill down into the legal data on hernia repair to determine what about the operation is most likely to get surgeons in trouble.
They found that a failure to diagnose a complication caused by damage to a nearby structure during the operation was the most common cause for a malpractice suit for hernia repair, Dr. Nadeem Haddad of the Mayo Clinic in Rochester, Minn., reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Hernia repair with more than 1 million cases annually is one of the most common surgical procedures,” Dr. Haddad said. “The most common type of operation for malpractice was inguinal hernia repair. The majority of cases were elective cases where the informed consent was not breached.”
The researchers sampled data on 250 malpractice cases arising from hernia surgery filed with the Westlaw Next legal database between 1985 and 2015, Dr. Haddad said. He added that the sample is not inclusive of all malpractice cases related to hernia repair in that time. “Our objective was to analyze reasons for litigation related to hernia repairs,” he said.
Among the hernia cases from the database, physicians (defendants) won 59%, patients (plaintiffs) won around 27%, and the remainder went to settlement before a verdict. Award payments ranged from $10,000 for a case where a Penrose drain was left in the patient to $16 million in the case of death of an infant due to perioperative hyperkalemia.
Eighty-four percent of the cases in the study involved inguinal or ventral hernia repair, Dr. Haddad said, but the Westlaw Next database did not differentiate between the two types of procedures. Nor did it separate out pediatric or adult repairs. Westlaw Next provides the alleged reason for litigation and gives details about lawsuits. The researchers classified the alleged reasons for the lawsuits based on the time period in which they happened: preoperatively, intraoperatively, and postoperatively.
“The single most common reason for malpractice in hernia repair was failure to diagnose a complication following damage to a surrounding structure,” Dr. Haddad said.
The state of New York had the highest number of medical malpractice cases (46), followed closely by California (42). In 15% of cases (38) the patients claimed a breach of informed consent by the surgeon
“While understanding the reasons why surgeons go to trial, the risk of future lawsuits may lessen if measures are enacted to prevent such outcomes,” Dr. Haddad said. “Following protocols in diagnosis and management, attention to good surgical technique, and keeping a checklist of possible complications are some of the ways to improve patients safety and decrease chances of litigation.”
Dr. Haddad and coauthors had no financial relationships to disclose.
AT THE ANNUAL ACADEMIC SURGICAL CONGRESS
Key clinical point: Failure to diagnose a complication caused by damage to a nearby structure during hernia repair surgery is the most common cause for a malpractice claim for hernia repair.
Major finding: In malpractice cases involving hernia surgery that go to trial, 59% of the rulings are for the plaintiff physicians and about 14% go to settlement before a judge or jury decision.
Data source: Sample of 250 hernia surgical malpractice cases from 1985 to 2015 in the Westlaw Next legal database.
Disclosures: The study authors reported having no financial disclosures.
Investigators recover nearly $755 million in health fraud
Government investigators recovered nearly $755 million in criminal and civil health fraud actions in 2015, according to new figures from the Health & Human Services Office of Inspector General (OIG).
The recoveries were made by Medicaid Fraud Control Units that operate in every state and consist of nearly 2,000 staff members.
This interactive OIG map shows the distribution of recoveries by state.
On Twitter @legal_med
Government investigators recovered nearly $755 million in criminal and civil health fraud actions in 2015, according to new figures from the Health & Human Services Office of Inspector General (OIG).
The recoveries were made by Medicaid Fraud Control Units that operate in every state and consist of nearly 2,000 staff members.
This interactive OIG map shows the distribution of recoveries by state.
On Twitter @legal_med
Government investigators recovered nearly $755 million in criminal and civil health fraud actions in 2015, according to new figures from the Health & Human Services Office of Inspector General (OIG).
The recoveries were made by Medicaid Fraud Control Units that operate in every state and consist of nearly 2,000 staff members.
This interactive OIG map shows the distribution of recoveries by state.
On Twitter @legal_med
Does Life, Liberty, and the Pursuit of Happiness Apply to Hospital Medicine?
Every American knows this well-known phrase from the Declaration of Independence, which describes the three “unalienable rights” ordained on humans by their Creator and which governments are bound to dutifully protect. But I wonder if the last unalienable right has implications for career happiness in the healthcare industry, particularly for hospitalists. With the phrase now being 240 years old, it has understandably permeated every inch of American society and affected every crevice of the American psyche. Despite having this decreed inalienable right of the pursuit of happiness, there is evidence of widespread dissatisfaction and unhappiness within our profession.
Speaking of happiness, I was listening to a 60 Minutes podcast entitled “Heroin in the Heartland.” It described a widespread affliction of heroin among mainstream middle- and upper-class suburban youths.1 During the piece, they interviewed several addicted youngsters and their parents. I was struck by the story of a young woman named Hannah; she described how and why she became addicted to heroin in her upper-middle-class high school in Columbus, Ohio. She described how heroin made her feel. On a scale of 1–10 in happiness, she said it made her feel like a “26.” She and many of her friends became addicted to the feeling of happiness that was infused into them, a feeling that could not be replicated without the use of the drug. She and her friends started their road to addiction in a quest for their unalienable right of the pursuit of happiness.
Contrast that story with the “unhappiness factor” that plagues U.S. physicians. A 2014 survey found that 54% of physicians reported at least one symptom of burnout.2 That figure was up from 46% in a 2011 survey. From 2011 to 2014, satisfaction with work-life balance dropped to 41% from 49%. Within that same time frame, burnout and dissatisfaction showed very little change in other U.S. working adults, widening the gap in dissatisfaction between physicians and non-physicians. Even after adjusting for age, sex, relationship status, and hours worked, physicians still were almost twice as likely to experience burnout than other working U.S. adults, and they only had an odds ratio of satisfaction of 0.68 (95% CI, 0.62–0.75) compared with non-physicians. In another recent (and sobering) meta-analysis, researchers found that about a third of all resident physicians report depression or depressive symptoms during their training (ranging from 21% to 43%, depending on the instrument used).3
Could it be that physicians in the U.S., in their quest for the pursuit of happiness, are looking for happiness in all the wrong ways? I read an article recently on DailyGood entitled “Does Trying to Be Happy Make Us Unhappy?”4 It describes several studies that purport that the more value people place on trying to become happy, the less happy they actually become. It turns out that in order for us to figure out if we are happy, we are forced to evaluate our current level of happiness and set that against some benchmark (usually from our own past) to analyze where we are. The mere act of doing this moves us from an experiential mode to an evaluation mode, which puts us out of touch with those things in life that can bring us joy and contentment.
Social scientists have found that when we are immersed in the present, we don’t report being happy in that moment, but we do report happiness later when reflecting on those moments. Ruminating about whether we are unhappy, depressed, burned out, or unsatisfied makes us inwardly focused and makes us lose the ability to become immersed in the present.
Scientists also have found that we tend to overestimate how external influences, such as getting a promotion or moving into a new job, will inflate our happiness and that we all adapt to new experiences and quickly return to our baseline happiness (as if the change never occurred). They’ve also found that when we pursue happiness as an individual state, we become inwardly focused and less likely to actually achieve happiness. People who are more outwardly focused on how others feel (and not how they themselves feel) are much more likely to achieve a state of sustained happiness.
Finally, researchers have found that happiness is more likely achieved by pursuing frequent positive emotions rather than intense positive emotions. Many of us search for single intense emotional experiences (the winning of a gold medal) in the pursuit of happiness, but researchers found that the frequency of positive emotions are much more important than the intensity of positive emotions.
So maybe, as physicians in pursuit of happiness, we are going about this pursuit all wrong, with resultant depression, dissatisfaction, and burnout. We can’t change the Declaration of Independence or the American psyche, but we can change how we perceive that pursuit.
Happiness is not a goal to be achieved but a state of mind to be savored. Immersing ourselves in our daily life, we should be outwardly focused on our colleagues and our patients. If we take this approach, there is no other profession better suited to actually achieving sustained happiness. TH
References
1. Preview: heroin in the heartland. CBS News website. Available at: www.cbsnews.com/videos/preview-heroin-in-the-heartland. Accessed Feb. 1, 2016.
2. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-1613. doi:10.1016/j.maocop.2015.08.023.
3. Mata DA, Ramos MA, Bansal N. Prevalence of depression and depressive symptoms among resident physicians: a systematic review and meta-analysis. JAMA. 2015;314(22):2373-2383. doi:10.1001/jama.2015.15845.
4. Grant A. Does trying to be happy make us unhappy? DailyGood website. Available at: http://www.dailygood.org/story/1187/does-trying-to-be-happy-make-us-unhappy-adam-grant/. Accessed Feb. 1, 2016.
Every American knows this well-known phrase from the Declaration of Independence, which describes the three “unalienable rights” ordained on humans by their Creator and which governments are bound to dutifully protect. But I wonder if the last unalienable right has implications for career happiness in the healthcare industry, particularly for hospitalists. With the phrase now being 240 years old, it has understandably permeated every inch of American society and affected every crevice of the American psyche. Despite having this decreed inalienable right of the pursuit of happiness, there is evidence of widespread dissatisfaction and unhappiness within our profession.
Speaking of happiness, I was listening to a 60 Minutes podcast entitled “Heroin in the Heartland.” It described a widespread affliction of heroin among mainstream middle- and upper-class suburban youths.1 During the piece, they interviewed several addicted youngsters and their parents. I was struck by the story of a young woman named Hannah; she described how and why she became addicted to heroin in her upper-middle-class high school in Columbus, Ohio. She described how heroin made her feel. On a scale of 1–10 in happiness, she said it made her feel like a “26.” She and many of her friends became addicted to the feeling of happiness that was infused into them, a feeling that could not be replicated without the use of the drug. She and her friends started their road to addiction in a quest for their unalienable right of the pursuit of happiness.
Contrast that story with the “unhappiness factor” that plagues U.S. physicians. A 2014 survey found that 54% of physicians reported at least one symptom of burnout.2 That figure was up from 46% in a 2011 survey. From 2011 to 2014, satisfaction with work-life balance dropped to 41% from 49%. Within that same time frame, burnout and dissatisfaction showed very little change in other U.S. working adults, widening the gap in dissatisfaction between physicians and non-physicians. Even after adjusting for age, sex, relationship status, and hours worked, physicians still were almost twice as likely to experience burnout than other working U.S. adults, and they only had an odds ratio of satisfaction of 0.68 (95% CI, 0.62–0.75) compared with non-physicians. In another recent (and sobering) meta-analysis, researchers found that about a third of all resident physicians report depression or depressive symptoms during their training (ranging from 21% to 43%, depending on the instrument used).3
Could it be that physicians in the U.S., in their quest for the pursuit of happiness, are looking for happiness in all the wrong ways? I read an article recently on DailyGood entitled “Does Trying to Be Happy Make Us Unhappy?”4 It describes several studies that purport that the more value people place on trying to become happy, the less happy they actually become. It turns out that in order for us to figure out if we are happy, we are forced to evaluate our current level of happiness and set that against some benchmark (usually from our own past) to analyze where we are. The mere act of doing this moves us from an experiential mode to an evaluation mode, which puts us out of touch with those things in life that can bring us joy and contentment.
Social scientists have found that when we are immersed in the present, we don’t report being happy in that moment, but we do report happiness later when reflecting on those moments. Ruminating about whether we are unhappy, depressed, burned out, or unsatisfied makes us inwardly focused and makes us lose the ability to become immersed in the present.
Scientists also have found that we tend to overestimate how external influences, such as getting a promotion or moving into a new job, will inflate our happiness and that we all adapt to new experiences and quickly return to our baseline happiness (as if the change never occurred). They’ve also found that when we pursue happiness as an individual state, we become inwardly focused and less likely to actually achieve happiness. People who are more outwardly focused on how others feel (and not how they themselves feel) are much more likely to achieve a state of sustained happiness.
Finally, researchers have found that happiness is more likely achieved by pursuing frequent positive emotions rather than intense positive emotions. Many of us search for single intense emotional experiences (the winning of a gold medal) in the pursuit of happiness, but researchers found that the frequency of positive emotions are much more important than the intensity of positive emotions.
So maybe, as physicians in pursuit of happiness, we are going about this pursuit all wrong, with resultant depression, dissatisfaction, and burnout. We can’t change the Declaration of Independence or the American psyche, but we can change how we perceive that pursuit.
Happiness is not a goal to be achieved but a state of mind to be savored. Immersing ourselves in our daily life, we should be outwardly focused on our colleagues and our patients. If we take this approach, there is no other profession better suited to actually achieving sustained happiness. TH
References
1. Preview: heroin in the heartland. CBS News website. Available at: www.cbsnews.com/videos/preview-heroin-in-the-heartland. Accessed Feb. 1, 2016.
2. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-1613. doi:10.1016/j.maocop.2015.08.023.
3. Mata DA, Ramos MA, Bansal N. Prevalence of depression and depressive symptoms among resident physicians: a systematic review and meta-analysis. JAMA. 2015;314(22):2373-2383. doi:10.1001/jama.2015.15845.
4. Grant A. Does trying to be happy make us unhappy? DailyGood website. Available at: http://www.dailygood.org/story/1187/does-trying-to-be-happy-make-us-unhappy-adam-grant/. Accessed Feb. 1, 2016.
Every American knows this well-known phrase from the Declaration of Independence, which describes the three “unalienable rights” ordained on humans by their Creator and which governments are bound to dutifully protect. But I wonder if the last unalienable right has implications for career happiness in the healthcare industry, particularly for hospitalists. With the phrase now being 240 years old, it has understandably permeated every inch of American society and affected every crevice of the American psyche. Despite having this decreed inalienable right of the pursuit of happiness, there is evidence of widespread dissatisfaction and unhappiness within our profession.
Speaking of happiness, I was listening to a 60 Minutes podcast entitled “Heroin in the Heartland.” It described a widespread affliction of heroin among mainstream middle- and upper-class suburban youths.1 During the piece, they interviewed several addicted youngsters and their parents. I was struck by the story of a young woman named Hannah; she described how and why she became addicted to heroin in her upper-middle-class high school in Columbus, Ohio. She described how heroin made her feel. On a scale of 1–10 in happiness, she said it made her feel like a “26.” She and many of her friends became addicted to the feeling of happiness that was infused into them, a feeling that could not be replicated without the use of the drug. She and her friends started their road to addiction in a quest for their unalienable right of the pursuit of happiness.
Contrast that story with the “unhappiness factor” that plagues U.S. physicians. A 2014 survey found that 54% of physicians reported at least one symptom of burnout.2 That figure was up from 46% in a 2011 survey. From 2011 to 2014, satisfaction with work-life balance dropped to 41% from 49%. Within that same time frame, burnout and dissatisfaction showed very little change in other U.S. working adults, widening the gap in dissatisfaction between physicians and non-physicians. Even after adjusting for age, sex, relationship status, and hours worked, physicians still were almost twice as likely to experience burnout than other working U.S. adults, and they only had an odds ratio of satisfaction of 0.68 (95% CI, 0.62–0.75) compared with non-physicians. In another recent (and sobering) meta-analysis, researchers found that about a third of all resident physicians report depression or depressive symptoms during their training (ranging from 21% to 43%, depending on the instrument used).3
Could it be that physicians in the U.S., in their quest for the pursuit of happiness, are looking for happiness in all the wrong ways? I read an article recently on DailyGood entitled “Does Trying to Be Happy Make Us Unhappy?”4 It describes several studies that purport that the more value people place on trying to become happy, the less happy they actually become. It turns out that in order for us to figure out if we are happy, we are forced to evaluate our current level of happiness and set that against some benchmark (usually from our own past) to analyze where we are. The mere act of doing this moves us from an experiential mode to an evaluation mode, which puts us out of touch with those things in life that can bring us joy and contentment.
Social scientists have found that when we are immersed in the present, we don’t report being happy in that moment, but we do report happiness later when reflecting on those moments. Ruminating about whether we are unhappy, depressed, burned out, or unsatisfied makes us inwardly focused and makes us lose the ability to become immersed in the present.
Scientists also have found that we tend to overestimate how external influences, such as getting a promotion or moving into a new job, will inflate our happiness and that we all adapt to new experiences and quickly return to our baseline happiness (as if the change never occurred). They’ve also found that when we pursue happiness as an individual state, we become inwardly focused and less likely to actually achieve happiness. People who are more outwardly focused on how others feel (and not how they themselves feel) are much more likely to achieve a state of sustained happiness.
Finally, researchers have found that happiness is more likely achieved by pursuing frequent positive emotions rather than intense positive emotions. Many of us search for single intense emotional experiences (the winning of a gold medal) in the pursuit of happiness, but researchers found that the frequency of positive emotions are much more important than the intensity of positive emotions.
So maybe, as physicians in pursuit of happiness, we are going about this pursuit all wrong, with resultant depression, dissatisfaction, and burnout. We can’t change the Declaration of Independence or the American psyche, but we can change how we perceive that pursuit.
Happiness is not a goal to be achieved but a state of mind to be savored. Immersing ourselves in our daily life, we should be outwardly focused on our colleagues and our patients. If we take this approach, there is no other profession better suited to actually achieving sustained happiness. TH
References
1. Preview: heroin in the heartland. CBS News website. Available at: www.cbsnews.com/videos/preview-heroin-in-the-heartland. Accessed Feb. 1, 2016.
2. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-1613. doi:10.1016/j.maocop.2015.08.023.
3. Mata DA, Ramos MA, Bansal N. Prevalence of depression and depressive symptoms among resident physicians: a systematic review and meta-analysis. JAMA. 2015;314(22):2373-2383. doi:10.1001/jama.2015.15845.
4. Grant A. Does trying to be happy make us unhappy? DailyGood website. Available at: http://www.dailygood.org/story/1187/does-trying-to-be-happy-make-us-unhappy-adam-grant/. Accessed Feb. 1, 2016.
Supreme Court: Fate of health care cases uncertain after Scalia death
The fate of several high-profile health care cases remains uncertain after the death of U.S. Supreme Court Justice Antonin Scalia.
The eight remaining justices will hear oral arguments on and weigh in on a range of cases this term. Justice Scalia’s death however, means the possibility of a tie vote in some cases, which could lead to conflicting case law across states.
“Most Supreme Court decisions are not decided on a 5-to-4 split, so presumably regular business will continue as to most of the cases they are deciding,” said Timothy S. Jost, health law professor at Washington and Lee University in Lexington, Va. “However, for some of the most important cases in health care – like the abortion decision or the contraceptive decision – it was likely there was going to be a 5-to-4 split. Of those cases, the justices can either hold them over or vote, in which case there [could] be a 4-to-4 split.”
If the court divides equally on a case, the lower court’s decision is affirmed. But the case would not have a Supreme Court precedent, meaning the lower ruling would apply only in the circuit court’s jurisdiction, said Eric J. Segall, a professor of law at Georgia State University, Atlanta.
In Whole Woman’s Health v. Cole, also known as Whole Woman’s Health v. Hellerstedt, for instance, a split would uphold an appellate decision that allowed abortion restrictions in Texas to go forward. In that case, the state is battling health providers over a mandate that abortion providers must have admitting privileges at a hospital within 30 miles and that abortion clinics must meet the same requirements as those of ambulatory surgical centers (ASCs). The 5th U.S. Circuit Court of Appeals ruled that the regulations do not impose an undue burden on a patient’s right to get an abortion.
“If a 5-4 [Supreme Court decision] upheld those restrictions, that would be national law for the whole country, and it would be a huge deal,” Mr. Segall said in an interview. “If it’s a 4-4 tie, than in Texas and two other states, the Texas decision would still be good law, but it would have no effect outside that circuit.”
In the case of Zubik v. Burwell however, a split vote would mean nationwide differences in how the Affordable Care Act’s contraceptive mandate is applied, said Ilya Shapiro, a senior fellow in constitutional studies at the Cato Institute. The Zubik case centers on whether the ACA contraceptive-coverage mandate and its “accommodation” violates the Religious Freedom Restoration Act by forcing religious nonprofits to act in violation of their beliefs. The 8th U.S. Circuit Court of Appeals struck down the exception twice, ruling that forcing organizations to offer contraceptive coverage – even indirectly – violates their religious rights. The 8th Circuit’s decisions are at odds with rulings by the 2nd and 5th Circuits.
Because of the conflicting lower court opinions, if the Zubik case were decided 4-4, “the regulation [would be] in place in parts of the country and not in others,” Mr. Shapiro said in an interview. “That seems untenable. Cases like that especially, the court would likely delay the arguments that are currently scheduled until the next term.”
Justices can decide whether to vote or rehear cases that were already heard with Justice Scalia in attendance, but are not yet decided. They can also dismiss or wait to address cases next term. Decisions that were made with Justice Scalia’s vote, but were not yet published, will be void, Mr. Shapiro said. As for Justice Scalia’s replacement, Mr. Shapiro noted that even if President Obama makes a nomination and it is confirmed by the Senate, it would be too late to consider cases this term.
Mr. Segall stressed that it’s too early to tell how Justice Scalia’s death will impact ongoing and future cases and the court as a whole.
“We don’t really have a precedent for this,” he said. “We’ve had vacancies before, but we’ve never had a vacancy in an election year where [the Court comprised] four conservative Republicans and four liberal Democrats. I think we should all step back. There are so many imponderables.”
Supreme Court analysts predict the eight justices will announce their decisions – or lack thereof – during the last week of June.
Justice Scalia was known as the high court’s most vocal conservative and was the longest-serving current justice on the court, hearing cases for 29 years.
What’s on the docket?
The Supreme Court is set to decide a number of significant health law cases this term. Here are some of the most pressing ones and the issues at stake.
Argument date: March 23, 2016
The court will decide whether an accommodation under the ACA contraceptive mandate violates the Religious Freedom Restoration Act by forcing religious nonprofits to act in violation of their beliefs, when the government has not proved that this compulsion is the least restrictive means of advancing a compelling interest. The accommodation clause refers to an exception for organizations that oppose coverage for contraceptives but are not exempted entities such as churches. The plaintiffs argue the process serves as a trigger that enables contraceptive use and makes the groups complicit. The government argues the exception does not impose a burden on the groups and that courts should not disregard the interest of employees who may not share employers’ religious beliefs.
Argument date: March 2, 2016
Justices will weigh whether two Texas regulations place an undue burden on a woman’s right to access an abortion. The regulations mandate that abortion providers have admitting privileges at a hospital within 30 miles of an abortion clinic in order to provide the service, and that all abortion clinics meet the same requirements as those of ambulatory surgical centers (ASCs). The plaintiffs, who are clinics and doctors, argue that both restrictions are unnecessary and limit access to abortion services. The Texas Department of State Health Services states the restrictions are reasonable and effective measures that raise the standard of care for abortion patients and ensure health and safety. The case is sometimes cited as Whole Woman’s Health v. Hellerstedt.
Universal Health Services v. United States ex rel. Escobar
Argument date: To be determined
In question is whether the legal theory used by the federal government to bring False Claims Act (FCA) lawsuits is valid. The case centers on a patient who died after receiving care by Universal Health Services Inc. (UHS) in Lawrence, Mass. The patient’s parents sued UHS under both the federal and state False Claims Act laws alleging that UHS providers were improperly licensed and made fraudulent government claims. The Supreme Court will answer whether the implied certification test for determining when claims “sufficiently plead falsity” under the FCA is constitutional and if so, if the relevant statute needs to explicitly state the conditions of payment with which the defendant allegedly failed to comply. Physician associations are concerned that a ruling for the plaintiff will expand the FCA’s reach and increase false claim lawsuits against health providers.
Gobeille v. Liberty Mutual Insurance Company
Argument date: Dec. 2, 2015
The Supreme Court will decide whether a self-funded insurer must share certain information, such as claims and member data, with Vermont’s all-payer database. The state argues the information is needed to improve the cost and effectiveness of health care and that an adverse ruling would chill reform efforts in other states with similar databases. Liberty Mutual, which maintains a self-insured health plan for its employees, argues that the Employee Retirement Income Security Act of 1973 (ERISA) preempts state statutes that provide for “all payer” health care databases, and that it does not have to supply the information. Analysts say the case will ultimately decide to what extent federal law can facilitate the centralized management of health care.
On Twitter @legal_med
The fate of several high-profile health care cases remains uncertain after the death of U.S. Supreme Court Justice Antonin Scalia.
The eight remaining justices will hear oral arguments on and weigh in on a range of cases this term. Justice Scalia’s death however, means the possibility of a tie vote in some cases, which could lead to conflicting case law across states.
“Most Supreme Court decisions are not decided on a 5-to-4 split, so presumably regular business will continue as to most of the cases they are deciding,” said Timothy S. Jost, health law professor at Washington and Lee University in Lexington, Va. “However, for some of the most important cases in health care – like the abortion decision or the contraceptive decision – it was likely there was going to be a 5-to-4 split. Of those cases, the justices can either hold them over or vote, in which case there [could] be a 4-to-4 split.”
If the court divides equally on a case, the lower court’s decision is affirmed. But the case would not have a Supreme Court precedent, meaning the lower ruling would apply only in the circuit court’s jurisdiction, said Eric J. Segall, a professor of law at Georgia State University, Atlanta.
In Whole Woman’s Health v. Cole, also known as Whole Woman’s Health v. Hellerstedt, for instance, a split would uphold an appellate decision that allowed abortion restrictions in Texas to go forward. In that case, the state is battling health providers over a mandate that abortion providers must have admitting privileges at a hospital within 30 miles and that abortion clinics must meet the same requirements as those of ambulatory surgical centers (ASCs). The 5th U.S. Circuit Court of Appeals ruled that the regulations do not impose an undue burden on a patient’s right to get an abortion.
“If a 5-4 [Supreme Court decision] upheld those restrictions, that would be national law for the whole country, and it would be a huge deal,” Mr. Segall said in an interview. “If it’s a 4-4 tie, than in Texas and two other states, the Texas decision would still be good law, but it would have no effect outside that circuit.”
In the case of Zubik v. Burwell however, a split vote would mean nationwide differences in how the Affordable Care Act’s contraceptive mandate is applied, said Ilya Shapiro, a senior fellow in constitutional studies at the Cato Institute. The Zubik case centers on whether the ACA contraceptive-coverage mandate and its “accommodation” violates the Religious Freedom Restoration Act by forcing religious nonprofits to act in violation of their beliefs. The 8th U.S. Circuit Court of Appeals struck down the exception twice, ruling that forcing organizations to offer contraceptive coverage – even indirectly – violates their religious rights. The 8th Circuit’s decisions are at odds with rulings by the 2nd and 5th Circuits.
Because of the conflicting lower court opinions, if the Zubik case were decided 4-4, “the regulation [would be] in place in parts of the country and not in others,” Mr. Shapiro said in an interview. “That seems untenable. Cases like that especially, the court would likely delay the arguments that are currently scheduled until the next term.”
Justices can decide whether to vote or rehear cases that were already heard with Justice Scalia in attendance, but are not yet decided. They can also dismiss or wait to address cases next term. Decisions that were made with Justice Scalia’s vote, but were not yet published, will be void, Mr. Shapiro said. As for Justice Scalia’s replacement, Mr. Shapiro noted that even if President Obama makes a nomination and it is confirmed by the Senate, it would be too late to consider cases this term.
Mr. Segall stressed that it’s too early to tell how Justice Scalia’s death will impact ongoing and future cases and the court as a whole.
“We don’t really have a precedent for this,” he said. “We’ve had vacancies before, but we’ve never had a vacancy in an election year where [the Court comprised] four conservative Republicans and four liberal Democrats. I think we should all step back. There are so many imponderables.”
Supreme Court analysts predict the eight justices will announce their decisions – or lack thereof – during the last week of June.
Justice Scalia was known as the high court’s most vocal conservative and was the longest-serving current justice on the court, hearing cases for 29 years.
What’s on the docket?
The Supreme Court is set to decide a number of significant health law cases this term. Here are some of the most pressing ones and the issues at stake.
Argument date: March 23, 2016
The court will decide whether an accommodation under the ACA contraceptive mandate violates the Religious Freedom Restoration Act by forcing religious nonprofits to act in violation of their beliefs, when the government has not proved that this compulsion is the least restrictive means of advancing a compelling interest. The accommodation clause refers to an exception for organizations that oppose coverage for contraceptives but are not exempted entities such as churches. The plaintiffs argue the process serves as a trigger that enables contraceptive use and makes the groups complicit. The government argues the exception does not impose a burden on the groups and that courts should not disregard the interest of employees who may not share employers’ religious beliefs.
Argument date: March 2, 2016
Justices will weigh whether two Texas regulations place an undue burden on a woman’s right to access an abortion. The regulations mandate that abortion providers have admitting privileges at a hospital within 30 miles of an abortion clinic in order to provide the service, and that all abortion clinics meet the same requirements as those of ambulatory surgical centers (ASCs). The plaintiffs, who are clinics and doctors, argue that both restrictions are unnecessary and limit access to abortion services. The Texas Department of State Health Services states the restrictions are reasonable and effective measures that raise the standard of care for abortion patients and ensure health and safety. The case is sometimes cited as Whole Woman’s Health v. Hellerstedt.
Universal Health Services v. United States ex rel. Escobar
Argument date: To be determined
In question is whether the legal theory used by the federal government to bring False Claims Act (FCA) lawsuits is valid. The case centers on a patient who died after receiving care by Universal Health Services Inc. (UHS) in Lawrence, Mass. The patient’s parents sued UHS under both the federal and state False Claims Act laws alleging that UHS providers were improperly licensed and made fraudulent government claims. The Supreme Court will answer whether the implied certification test for determining when claims “sufficiently plead falsity” under the FCA is constitutional and if so, if the relevant statute needs to explicitly state the conditions of payment with which the defendant allegedly failed to comply. Physician associations are concerned that a ruling for the plaintiff will expand the FCA’s reach and increase false claim lawsuits against health providers.
Gobeille v. Liberty Mutual Insurance Company
Argument date: Dec. 2, 2015
The Supreme Court will decide whether a self-funded insurer must share certain information, such as claims and member data, with Vermont’s all-payer database. The state argues the information is needed to improve the cost and effectiveness of health care and that an adverse ruling would chill reform efforts in other states with similar databases. Liberty Mutual, which maintains a self-insured health plan for its employees, argues that the Employee Retirement Income Security Act of 1973 (ERISA) preempts state statutes that provide for “all payer” health care databases, and that it does not have to supply the information. Analysts say the case will ultimately decide to what extent federal law can facilitate the centralized management of health care.
On Twitter @legal_med
The fate of several high-profile health care cases remains uncertain after the death of U.S. Supreme Court Justice Antonin Scalia.
The eight remaining justices will hear oral arguments on and weigh in on a range of cases this term. Justice Scalia’s death however, means the possibility of a tie vote in some cases, which could lead to conflicting case law across states.
“Most Supreme Court decisions are not decided on a 5-to-4 split, so presumably regular business will continue as to most of the cases they are deciding,” said Timothy S. Jost, health law professor at Washington and Lee University in Lexington, Va. “However, for some of the most important cases in health care – like the abortion decision or the contraceptive decision – it was likely there was going to be a 5-to-4 split. Of those cases, the justices can either hold them over or vote, in which case there [could] be a 4-to-4 split.”
If the court divides equally on a case, the lower court’s decision is affirmed. But the case would not have a Supreme Court precedent, meaning the lower ruling would apply only in the circuit court’s jurisdiction, said Eric J. Segall, a professor of law at Georgia State University, Atlanta.
In Whole Woman’s Health v. Cole, also known as Whole Woman’s Health v. Hellerstedt, for instance, a split would uphold an appellate decision that allowed abortion restrictions in Texas to go forward. In that case, the state is battling health providers over a mandate that abortion providers must have admitting privileges at a hospital within 30 miles and that abortion clinics must meet the same requirements as those of ambulatory surgical centers (ASCs). The 5th U.S. Circuit Court of Appeals ruled that the regulations do not impose an undue burden on a patient’s right to get an abortion.
“If a 5-4 [Supreme Court decision] upheld those restrictions, that would be national law for the whole country, and it would be a huge deal,” Mr. Segall said in an interview. “If it’s a 4-4 tie, than in Texas and two other states, the Texas decision would still be good law, but it would have no effect outside that circuit.”
In the case of Zubik v. Burwell however, a split vote would mean nationwide differences in how the Affordable Care Act’s contraceptive mandate is applied, said Ilya Shapiro, a senior fellow in constitutional studies at the Cato Institute. The Zubik case centers on whether the ACA contraceptive-coverage mandate and its “accommodation” violates the Religious Freedom Restoration Act by forcing religious nonprofits to act in violation of their beliefs. The 8th U.S. Circuit Court of Appeals struck down the exception twice, ruling that forcing organizations to offer contraceptive coverage – even indirectly – violates their religious rights. The 8th Circuit’s decisions are at odds with rulings by the 2nd and 5th Circuits.
Because of the conflicting lower court opinions, if the Zubik case were decided 4-4, “the regulation [would be] in place in parts of the country and not in others,” Mr. Shapiro said in an interview. “That seems untenable. Cases like that especially, the court would likely delay the arguments that are currently scheduled until the next term.”
Justices can decide whether to vote or rehear cases that were already heard with Justice Scalia in attendance, but are not yet decided. They can also dismiss or wait to address cases next term. Decisions that were made with Justice Scalia’s vote, but were not yet published, will be void, Mr. Shapiro said. As for Justice Scalia’s replacement, Mr. Shapiro noted that even if President Obama makes a nomination and it is confirmed by the Senate, it would be too late to consider cases this term.
Mr. Segall stressed that it’s too early to tell how Justice Scalia’s death will impact ongoing and future cases and the court as a whole.
“We don’t really have a precedent for this,” he said. “We’ve had vacancies before, but we’ve never had a vacancy in an election year where [the Court comprised] four conservative Republicans and four liberal Democrats. I think we should all step back. There are so many imponderables.”
Supreme Court analysts predict the eight justices will announce their decisions – or lack thereof – during the last week of June.
Justice Scalia was known as the high court’s most vocal conservative and was the longest-serving current justice on the court, hearing cases for 29 years.
What’s on the docket?
The Supreme Court is set to decide a number of significant health law cases this term. Here are some of the most pressing ones and the issues at stake.
Argument date: March 23, 2016
The court will decide whether an accommodation under the ACA contraceptive mandate violates the Religious Freedom Restoration Act by forcing religious nonprofits to act in violation of their beliefs, when the government has not proved that this compulsion is the least restrictive means of advancing a compelling interest. The accommodation clause refers to an exception for organizations that oppose coverage for contraceptives but are not exempted entities such as churches. The plaintiffs argue the process serves as a trigger that enables contraceptive use and makes the groups complicit. The government argues the exception does not impose a burden on the groups and that courts should not disregard the interest of employees who may not share employers’ religious beliefs.
Argument date: March 2, 2016
Justices will weigh whether two Texas regulations place an undue burden on a woman’s right to access an abortion. The regulations mandate that abortion providers have admitting privileges at a hospital within 30 miles of an abortion clinic in order to provide the service, and that all abortion clinics meet the same requirements as those of ambulatory surgical centers (ASCs). The plaintiffs, who are clinics and doctors, argue that both restrictions are unnecessary and limit access to abortion services. The Texas Department of State Health Services states the restrictions are reasonable and effective measures that raise the standard of care for abortion patients and ensure health and safety. The case is sometimes cited as Whole Woman’s Health v. Hellerstedt.
Universal Health Services v. United States ex rel. Escobar
Argument date: To be determined
In question is whether the legal theory used by the federal government to bring False Claims Act (FCA) lawsuits is valid. The case centers on a patient who died after receiving care by Universal Health Services Inc. (UHS) in Lawrence, Mass. The patient’s parents sued UHS under both the federal and state False Claims Act laws alleging that UHS providers were improperly licensed and made fraudulent government claims. The Supreme Court will answer whether the implied certification test for determining when claims “sufficiently plead falsity” under the FCA is constitutional and if so, if the relevant statute needs to explicitly state the conditions of payment with which the defendant allegedly failed to comply. Physician associations are concerned that a ruling for the plaintiff will expand the FCA’s reach and increase false claim lawsuits against health providers.
Gobeille v. Liberty Mutual Insurance Company
Argument date: Dec. 2, 2015
The Supreme Court will decide whether a self-funded insurer must share certain information, such as claims and member data, with Vermont’s all-payer database. The state argues the information is needed to improve the cost and effectiveness of health care and that an adverse ruling would chill reform efforts in other states with similar databases. Liberty Mutual, which maintains a self-insured health plan for its employees, argues that the Employee Retirement Income Security Act of 1973 (ERISA) preempts state statutes that provide for “all payer” health care databases, and that it does not have to supply the information. Analysts say the case will ultimately decide to what extent federal law can facilitate the centralized management of health care.
On Twitter @legal_med
Change to NPDB guidebook redefines ‘investigation’
AUSTIN, TEX. – Physicians could face more reportable actions to the National Practitioner Data Bank (NPDB) under changes to the data bank’s guidebook.
In its last update of the guidebook, the Health Resources and Services Administration (HRSA) expanded its definition of “investigation” and now interprets the term “expansively” and will not be limited by how hospital bylaws define an investigation.
Data bank officials will review a health care entity’s bylaws and other documents for assistance in determining whether an investigation has started or is ongoing, but they retain “the ultimate authority to determine whether an investigation exists,” according to the guidebook.
The change is significant because it means more reviews by health care entities could be considered investigations by the data bank, regardless of how hospitals regard the assessment, Michael A. Cassidy said at the meeting, which was held by the American Health Lawyers Association.
Investigations alone are not reportable to the data bank, but actions taken by doctors during investigations are. This includes:
• Resignation of clinical privileges.
• Failure to renew clinical privileges.
• Lapse of license.
• Leave of absence.
• Relinquishment of panel membership.
The guidebook notes that a routine, formal peer review process under which a health care entity evaluates, against defined measures, privilege-specific competence of all practitioners is not considered an investigation by the NPDB. However, a formal, “targeted process used when issues related to a specific practitioner’s professional competence or conduct are identified” is considered an investigation for purposes of reporting to the NPDB.
The catch for doctors is that their awareness of an investigation is immaterial, said Mr. Cassidy, a Pittsburgh-based health law attorney. In the past, a doctor’s awareness of an investigation was a prerequisite for filing a report with the data bank.
The HRSA’s stance is that “physicians’ awareness of the investigation doesn’t have any impact on whether it’s an investigation or not,” Mr. Cassidy said in an interview. “From a physician standpoint, they want to be aware all the time whether an investigation has started. If they don’t find out an investigation has started until after they get a decision, it’s too late to forestall any of the reporting consequences.”
In addition, the NPDB considers an investigation ongoing until the health care entity takes a final action or formally closes the investigation. Formal closure is not defined, but written notice to the doctor would likely be the best evidence, according to Mr. Cassidy.
Changing medical staff bylaws to include doctors early in the process could help mitigate future investigation woes, he advised.
“It is not enough simply to provide that the doctor will be advised when an investigation starts because that triggers the reporting requirements, and places the parties in an adversarial position,” he said. “The bylaws should require notification to the physician whenever a complaint is made so that the physician can defend himself before it becomes an investigation.”
On Twitter @legal_med
AUSTIN, TEX. – Physicians could face more reportable actions to the National Practitioner Data Bank (NPDB) under changes to the data bank’s guidebook.
In its last update of the guidebook, the Health Resources and Services Administration (HRSA) expanded its definition of “investigation” and now interprets the term “expansively” and will not be limited by how hospital bylaws define an investigation.
Data bank officials will review a health care entity’s bylaws and other documents for assistance in determining whether an investigation has started or is ongoing, but they retain “the ultimate authority to determine whether an investigation exists,” according to the guidebook.
The change is significant because it means more reviews by health care entities could be considered investigations by the data bank, regardless of how hospitals regard the assessment, Michael A. Cassidy said at the meeting, which was held by the American Health Lawyers Association.
Investigations alone are not reportable to the data bank, but actions taken by doctors during investigations are. This includes:
• Resignation of clinical privileges.
• Failure to renew clinical privileges.
• Lapse of license.
• Leave of absence.
• Relinquishment of panel membership.
The guidebook notes that a routine, formal peer review process under which a health care entity evaluates, against defined measures, privilege-specific competence of all practitioners is not considered an investigation by the NPDB. However, a formal, “targeted process used when issues related to a specific practitioner’s professional competence or conduct are identified” is considered an investigation for purposes of reporting to the NPDB.
The catch for doctors is that their awareness of an investigation is immaterial, said Mr. Cassidy, a Pittsburgh-based health law attorney. In the past, a doctor’s awareness of an investigation was a prerequisite for filing a report with the data bank.
The HRSA’s stance is that “physicians’ awareness of the investigation doesn’t have any impact on whether it’s an investigation or not,” Mr. Cassidy said in an interview. “From a physician standpoint, they want to be aware all the time whether an investigation has started. If they don’t find out an investigation has started until after they get a decision, it’s too late to forestall any of the reporting consequences.”
In addition, the NPDB considers an investigation ongoing until the health care entity takes a final action or formally closes the investigation. Formal closure is not defined, but written notice to the doctor would likely be the best evidence, according to Mr. Cassidy.
Changing medical staff bylaws to include doctors early in the process could help mitigate future investigation woes, he advised.
“It is not enough simply to provide that the doctor will be advised when an investigation starts because that triggers the reporting requirements, and places the parties in an adversarial position,” he said. “The bylaws should require notification to the physician whenever a complaint is made so that the physician can defend himself before it becomes an investigation.”
On Twitter @legal_med
AUSTIN, TEX. – Physicians could face more reportable actions to the National Practitioner Data Bank (NPDB) under changes to the data bank’s guidebook.
In its last update of the guidebook, the Health Resources and Services Administration (HRSA) expanded its definition of “investigation” and now interprets the term “expansively” and will not be limited by how hospital bylaws define an investigation.
Data bank officials will review a health care entity’s bylaws and other documents for assistance in determining whether an investigation has started or is ongoing, but they retain “the ultimate authority to determine whether an investigation exists,” according to the guidebook.
The change is significant because it means more reviews by health care entities could be considered investigations by the data bank, regardless of how hospitals regard the assessment, Michael A. Cassidy said at the meeting, which was held by the American Health Lawyers Association.
Investigations alone are not reportable to the data bank, but actions taken by doctors during investigations are. This includes:
• Resignation of clinical privileges.
• Failure to renew clinical privileges.
• Lapse of license.
• Leave of absence.
• Relinquishment of panel membership.
The guidebook notes that a routine, formal peer review process under which a health care entity evaluates, against defined measures, privilege-specific competence of all practitioners is not considered an investigation by the NPDB. However, a formal, “targeted process used when issues related to a specific practitioner’s professional competence or conduct are identified” is considered an investigation for purposes of reporting to the NPDB.
The catch for doctors is that their awareness of an investigation is immaterial, said Mr. Cassidy, a Pittsburgh-based health law attorney. In the past, a doctor’s awareness of an investigation was a prerequisite for filing a report with the data bank.
The HRSA’s stance is that “physicians’ awareness of the investigation doesn’t have any impact on whether it’s an investigation or not,” Mr. Cassidy said in an interview. “From a physician standpoint, they want to be aware all the time whether an investigation has started. If they don’t find out an investigation has started until after they get a decision, it’s too late to forestall any of the reporting consequences.”
In addition, the NPDB considers an investigation ongoing until the health care entity takes a final action or formally closes the investigation. Formal closure is not defined, but written notice to the doctor would likely be the best evidence, according to Mr. Cassidy.
Changing medical staff bylaws to include doctors early in the process could help mitigate future investigation woes, he advised.
“It is not enough simply to provide that the doctor will be advised when an investigation starts because that triggers the reporting requirements, and places the parties in an adversarial position,” he said. “The bylaws should require notification to the physician whenever a complaint is made so that the physician can defend himself before it becomes an investigation.”
On Twitter @legal_med
AT THE PHYSICIANS AND HOSPITALS LAW INSTITUTE
Doctors, payers collaborate to simplify and align quality measures
The Centers for Medicare & Medicaid Services and America’s Health Insurance Plans on Feb 16 announced a set of core quality measures across seven areas that will serve as the foundation for a more uniform set of quality metrics that will be used by both public and private payers.
The CMS and AHIP are working with the National Quality Forum, medical specialty societies, employer groups, and consumer groups under an umbrella organization called the Core Quality Measures Collaborative. Together, they derived a set of measures that are “meaningful to patients, consumers, and physicians, while reducing variability in measure selection, collection burden, and cost,” the CMS noted in a fact sheet.
Involved medical specialty societies include the American Academy of Family Physicians, American College of Cardiology, American Heart Association, American College of Physicians, American Gastroenterological Association, HIV Medicine Association, Infectious Diseases Society of America, American Academy of Pediatrics, American Society of Clinical Oncology, and the American Medical Association.
The collaborative announced core measures in seven areas: accountable care organizations/patient centered medical homes/primary care, cardiology, gastroenterology, HIV and hepatitis C, medical oncology, obstetrics and gynecology, and orthopedics. Measures in additional areas will be released in the future and the core sets will be reviewed and updated on a regular basis.
“I think [this collaboration] strikes the best balance between what is feasible and what is desirable,” Dr. Ziad Gellad, chair of the AGA Quality Measures Committee, said in an interview.
For Medicare, Medicaid, and other public programs, the measure sets will be implemented and updated through the physician fee schedule in the coming Merit-Based Incentive Payment System (MIPS) and alternative payment models (APMs). Private payers are expected to begin implementing these quality measures as physician contracts come up for renewal.
“I think one of the biggest challenges will be how to collect these measures, because the decision about what measures to include was only driven in part by the feasibility,” Dr. Gellad said. “A large part was driven by what are the best metrics and what are most important outcomes and processes to evaluate. I think in terms of feasibility, that is going to be the next important question. How do you improve the feasibility of these measurements in practice?”
Electronic health records will play an integral part, as a FAQ released by AHIP notes that several of the measures “require that clinical data be extracted from EHRs or registries or be self-reported by clinicians.” It adds that clinicians and payers “will need to work together to create a reporting infrastructure for such measures” in areas where it is currently lacking.
The Centers for Medicare & Medicaid Services and America’s Health Insurance Plans on Feb 16 announced a set of core quality measures across seven areas that will serve as the foundation for a more uniform set of quality metrics that will be used by both public and private payers.
The CMS and AHIP are working with the National Quality Forum, medical specialty societies, employer groups, and consumer groups under an umbrella organization called the Core Quality Measures Collaborative. Together, they derived a set of measures that are “meaningful to patients, consumers, and physicians, while reducing variability in measure selection, collection burden, and cost,” the CMS noted in a fact sheet.
Involved medical specialty societies include the American Academy of Family Physicians, American College of Cardiology, American Heart Association, American College of Physicians, American Gastroenterological Association, HIV Medicine Association, Infectious Diseases Society of America, American Academy of Pediatrics, American Society of Clinical Oncology, and the American Medical Association.
The collaborative announced core measures in seven areas: accountable care organizations/patient centered medical homes/primary care, cardiology, gastroenterology, HIV and hepatitis C, medical oncology, obstetrics and gynecology, and orthopedics. Measures in additional areas will be released in the future and the core sets will be reviewed and updated on a regular basis.
“I think [this collaboration] strikes the best balance between what is feasible and what is desirable,” Dr. Ziad Gellad, chair of the AGA Quality Measures Committee, said in an interview.
For Medicare, Medicaid, and other public programs, the measure sets will be implemented and updated through the physician fee schedule in the coming Merit-Based Incentive Payment System (MIPS) and alternative payment models (APMs). Private payers are expected to begin implementing these quality measures as physician contracts come up for renewal.
“I think one of the biggest challenges will be how to collect these measures, because the decision about what measures to include was only driven in part by the feasibility,” Dr. Gellad said. “A large part was driven by what are the best metrics and what are most important outcomes and processes to evaluate. I think in terms of feasibility, that is going to be the next important question. How do you improve the feasibility of these measurements in practice?”
Electronic health records will play an integral part, as a FAQ released by AHIP notes that several of the measures “require that clinical data be extracted from EHRs or registries or be self-reported by clinicians.” It adds that clinicians and payers “will need to work together to create a reporting infrastructure for such measures” in areas where it is currently lacking.
The Centers for Medicare & Medicaid Services and America’s Health Insurance Plans on Feb 16 announced a set of core quality measures across seven areas that will serve as the foundation for a more uniform set of quality metrics that will be used by both public and private payers.
The CMS and AHIP are working with the National Quality Forum, medical specialty societies, employer groups, and consumer groups under an umbrella organization called the Core Quality Measures Collaborative. Together, they derived a set of measures that are “meaningful to patients, consumers, and physicians, while reducing variability in measure selection, collection burden, and cost,” the CMS noted in a fact sheet.
Involved medical specialty societies include the American Academy of Family Physicians, American College of Cardiology, American Heart Association, American College of Physicians, American Gastroenterological Association, HIV Medicine Association, Infectious Diseases Society of America, American Academy of Pediatrics, American Society of Clinical Oncology, and the American Medical Association.
The collaborative announced core measures in seven areas: accountable care organizations/patient centered medical homes/primary care, cardiology, gastroenterology, HIV and hepatitis C, medical oncology, obstetrics and gynecology, and orthopedics. Measures in additional areas will be released in the future and the core sets will be reviewed and updated on a regular basis.
“I think [this collaboration] strikes the best balance between what is feasible and what is desirable,” Dr. Ziad Gellad, chair of the AGA Quality Measures Committee, said in an interview.
For Medicare, Medicaid, and other public programs, the measure sets will be implemented and updated through the physician fee schedule in the coming Merit-Based Incentive Payment System (MIPS) and alternative payment models (APMs). Private payers are expected to begin implementing these quality measures as physician contracts come up for renewal.
“I think one of the biggest challenges will be how to collect these measures, because the decision about what measures to include was only driven in part by the feasibility,” Dr. Gellad said. “A large part was driven by what are the best metrics and what are most important outcomes and processes to evaluate. I think in terms of feasibility, that is going to be the next important question. How do you improve the feasibility of these measurements in practice?”
Electronic health records will play an integral part, as a FAQ released by AHIP notes that several of the measures “require that clinical data be extracted from EHRs or registries or be self-reported by clinicians.” It adds that clinicians and payers “will need to work together to create a reporting infrastructure for such measures” in areas where it is currently lacking.
Dr. Hospitalist: Routine Provider Evaluations Are a Necessary, Valuable Tool
Dear Dr. Hospitalist:
We have several physicians in our large academic group whom I hate to follow when picking up teams. There have only been a few situations when I thought there was a clear knowledge deficit, but the most irritating problem is that they don’t discharge patients. I’ve only been in the group for several years, so I don’t want to come across as a complainer. However, I am concerned about poor patient care and the work left to me to discharge patients. How can I help these physicians improve without damaging my relationship with them?
Dr. Frustrated
Dr. Hospitalist responds:
You bring up a problem that I’m certain many of us in hospital medicine have experienced at some point in our career. Since the “practice” of medicine can often be done with much variability, there are many gray areas that occur during the care of patients. However, we all know it is the transitioning of patients into and out of the hospital that is the most labor-intensive period of their care. If at all possible, the discharge process is best performed by the person with the most longitudinal knowledge of the patient’s hospital course.
Your leadership team has the responsibility to assess the quality and quantity of work of all team members. The periodic assessment of a clinician’s skill and aptitude, as well as the safety of care delivered to patients, can be done in several ways. Typically, the initial assessment is done by focused professional practice evaluations (FPPEs) and later by ongoing professional practice evaluations (OPPEs). The Joint Commission created these tools in 2007 to help determine if the quality of care by clinicians fell below an acceptable level.
FPPEs, as defined by the commission, are “the time limited evaluation of practitioner competence in performing a specific privilege.” They are usually done three to six months after the initial credentialing period, when a new or additional privilege is requested after the initial appointment, or when a condition or issue affecting the delivery of safe and high-quality care is identified.
OPPEs, as the name suggests, are typically done on an ongoing basis (usually annually). These practitioner-specific reports are best utilized as screening tools, and when unusual or aberrant tendencies are observed, a more detailed analysis typically is required.
Although these formal evaluations are carried out by chart review and analysis of data collected by the hospital, they should always be supported by discreet and candid conversations with other frontline team members. It is during these sessions that individuals should take the opportunity to express their opinions regarding the care delivered by their colleagues. From my experience, because of the shared care of patients in hospital medicine, if there is a problem with an individual’s professionalism or clinical abilities, it is usually well-known by others in the group.
If for some reason group leaders are not performing these mandated evaluations (and thus risking regulatory sanctions) or don’t have a formal mechanism in place, I would encourage them to establish one. In the interim, I would discreetly address the individuals and share your concerns. Many times, the problems you mention can be resolved with awareness, mentoring, and/or proctoring, but like any needed corrective actions, they must first be acknowledged.
Good luck! TH
Dear Dr. Hospitalist:
We have several physicians in our large academic group whom I hate to follow when picking up teams. There have only been a few situations when I thought there was a clear knowledge deficit, but the most irritating problem is that they don’t discharge patients. I’ve only been in the group for several years, so I don’t want to come across as a complainer. However, I am concerned about poor patient care and the work left to me to discharge patients. How can I help these physicians improve without damaging my relationship with them?
Dr. Frustrated
Dr. Hospitalist responds:
You bring up a problem that I’m certain many of us in hospital medicine have experienced at some point in our career. Since the “practice” of medicine can often be done with much variability, there are many gray areas that occur during the care of patients. However, we all know it is the transitioning of patients into and out of the hospital that is the most labor-intensive period of their care. If at all possible, the discharge process is best performed by the person with the most longitudinal knowledge of the patient’s hospital course.
Your leadership team has the responsibility to assess the quality and quantity of work of all team members. The periodic assessment of a clinician’s skill and aptitude, as well as the safety of care delivered to patients, can be done in several ways. Typically, the initial assessment is done by focused professional practice evaluations (FPPEs) and later by ongoing professional practice evaluations (OPPEs). The Joint Commission created these tools in 2007 to help determine if the quality of care by clinicians fell below an acceptable level.
FPPEs, as defined by the commission, are “the time limited evaluation of practitioner competence in performing a specific privilege.” They are usually done three to six months after the initial credentialing period, when a new or additional privilege is requested after the initial appointment, or when a condition or issue affecting the delivery of safe and high-quality care is identified.
OPPEs, as the name suggests, are typically done on an ongoing basis (usually annually). These practitioner-specific reports are best utilized as screening tools, and when unusual or aberrant tendencies are observed, a more detailed analysis typically is required.
Although these formal evaluations are carried out by chart review and analysis of data collected by the hospital, they should always be supported by discreet and candid conversations with other frontline team members. It is during these sessions that individuals should take the opportunity to express their opinions regarding the care delivered by their colleagues. From my experience, because of the shared care of patients in hospital medicine, if there is a problem with an individual’s professionalism or clinical abilities, it is usually well-known by others in the group.
If for some reason group leaders are not performing these mandated evaluations (and thus risking regulatory sanctions) or don’t have a formal mechanism in place, I would encourage them to establish one. In the interim, I would discreetly address the individuals and share your concerns. Many times, the problems you mention can be resolved with awareness, mentoring, and/or proctoring, but like any needed corrective actions, they must first be acknowledged.
Good luck! TH
Dear Dr. Hospitalist:
We have several physicians in our large academic group whom I hate to follow when picking up teams. There have only been a few situations when I thought there was a clear knowledge deficit, but the most irritating problem is that they don’t discharge patients. I’ve only been in the group for several years, so I don’t want to come across as a complainer. However, I am concerned about poor patient care and the work left to me to discharge patients. How can I help these physicians improve without damaging my relationship with them?
Dr. Frustrated
Dr. Hospitalist responds:
You bring up a problem that I’m certain many of us in hospital medicine have experienced at some point in our career. Since the “practice” of medicine can often be done with much variability, there are many gray areas that occur during the care of patients. However, we all know it is the transitioning of patients into and out of the hospital that is the most labor-intensive period of their care. If at all possible, the discharge process is best performed by the person with the most longitudinal knowledge of the patient’s hospital course.
Your leadership team has the responsibility to assess the quality and quantity of work of all team members. The periodic assessment of a clinician’s skill and aptitude, as well as the safety of care delivered to patients, can be done in several ways. Typically, the initial assessment is done by focused professional practice evaluations (FPPEs) and later by ongoing professional practice evaluations (OPPEs). The Joint Commission created these tools in 2007 to help determine if the quality of care by clinicians fell below an acceptable level.
FPPEs, as defined by the commission, are “the time limited evaluation of practitioner competence in performing a specific privilege.” They are usually done three to six months after the initial credentialing period, when a new or additional privilege is requested after the initial appointment, or when a condition or issue affecting the delivery of safe and high-quality care is identified.
OPPEs, as the name suggests, are typically done on an ongoing basis (usually annually). These practitioner-specific reports are best utilized as screening tools, and when unusual or aberrant tendencies are observed, a more detailed analysis typically is required.
Although these formal evaluations are carried out by chart review and analysis of data collected by the hospital, they should always be supported by discreet and candid conversations with other frontline team members. It is during these sessions that individuals should take the opportunity to express their opinions regarding the care delivered by their colleagues. From my experience, because of the shared care of patients in hospital medicine, if there is a problem with an individual’s professionalism or clinical abilities, it is usually well-known by others in the group.
If for some reason group leaders are not performing these mandated evaluations (and thus risking regulatory sanctions) or don’t have a formal mechanism in place, I would encourage them to establish one. In the interim, I would discreetly address the individuals and share your concerns. Many times, the problems you mention can be resolved with awareness, mentoring, and/or proctoring, but like any needed corrective actions, they must first be acknowledged.
Good luck! TH
CMS clarifies how to report Medicare overpayments
There is finally some clarity about how to report and return Medicare overpayments, under a final rule released by the Centers for Medicare & Medicaid Services Feb. 11.
The final regulation clarifies that health providers have identified an overpayment when they “have or should have, through the exercise of reasonable diligence, determined [they have] received an overpayment and quantified the amount of the overpayment.”
Overpayments must be reported and returned only if identified within 6 years of the date the payment was received – down from the 10 years included in the proposed rule released in 2012. Physician organizations and other health care stakeholders had criticized the proposal, calling the 10-year time frame unreasonable and burdensome.
The revised definition of identification makes more sense for physicians, particularly that identification exists when providers have quantified the amount of the overpayment, said Scot T. Hasselman, a Washington health law attorney. In many cases, it takes time to decipher how much money is owed after discovering a potential overpayment, he said in an interview.
“This all goes to: When does the clock begin ticking for the 60 days?” he said. “The language in the final rule provides for a standard that is easier to apply.
The 6-year time frame is also more reasonable and will save practices money by limiting their audit obligations, Mr. Hasselman noted.
The final rule also allows the 60-day deadline for returning overpayments to be suspended if a provider requests an extended repayment schedule. In the past, “people could be in a real pickle if they didn’t have the money to return,” Mr. Hasselman said. “This [provision] is important, especially for smaller [practices] and physicians who may not have big credit lines or the cash flow of an institutional provider.”
The final rule also clarifies how to report overpayments. Providers and suppliers must use an applicable claims adjustment, credit balance, self-reported refund, or another appropriate process to satisfy the obligation to report and return overpayments, the rule states. If a provider has reported a self-identified overpayment using the self-referral disclosure protocol managed by CMS or the self-disclosure protocol managed by the HHS Office of Inspector General (OIG), the provider is considered to be in compliance with the rule.
But the final rule is not entirely positive, according to Houston-based health law attorney Michael E. Clark. Many health providers had requested clarification about the level of resources small providers are expected to devote to investigating potential overpayments. Commenters suggested CMS allow for more defined overpayment responses based on provider size and resources. The agency did not do so, saying that providers, “large and small have a duty to ensure claims are accurate and appropriate and to report and return overpayments they have received.”
Refusing to allow scalable responses is unfortunate for practices that do not have the ability to react to overpayments as robustly as larger chains, Mr. Clark said.
“The agency was unwilling to go that far,” Mr. Clark said. “They’re not going to give a lesser standard for smaller providers. They’re going to look at the facts and circumstances. It gives [CMS] subjectivity, whereas doctors would rather have more clarification and objectivity.”
On Twitter @legal_med
There is finally some clarity about how to report and return Medicare overpayments, under a final rule released by the Centers for Medicare & Medicaid Services Feb. 11.
The final regulation clarifies that health providers have identified an overpayment when they “have or should have, through the exercise of reasonable diligence, determined [they have] received an overpayment and quantified the amount of the overpayment.”
Overpayments must be reported and returned only if identified within 6 years of the date the payment was received – down from the 10 years included in the proposed rule released in 2012. Physician organizations and other health care stakeholders had criticized the proposal, calling the 10-year time frame unreasonable and burdensome.
The revised definition of identification makes more sense for physicians, particularly that identification exists when providers have quantified the amount of the overpayment, said Scot T. Hasselman, a Washington health law attorney. In many cases, it takes time to decipher how much money is owed after discovering a potential overpayment, he said in an interview.
“This all goes to: When does the clock begin ticking for the 60 days?” he said. “The language in the final rule provides for a standard that is easier to apply.
The 6-year time frame is also more reasonable and will save practices money by limiting their audit obligations, Mr. Hasselman noted.
The final rule also allows the 60-day deadline for returning overpayments to be suspended if a provider requests an extended repayment schedule. In the past, “people could be in a real pickle if they didn’t have the money to return,” Mr. Hasselman said. “This [provision] is important, especially for smaller [practices] and physicians who may not have big credit lines or the cash flow of an institutional provider.”
The final rule also clarifies how to report overpayments. Providers and suppliers must use an applicable claims adjustment, credit balance, self-reported refund, or another appropriate process to satisfy the obligation to report and return overpayments, the rule states. If a provider has reported a self-identified overpayment using the self-referral disclosure protocol managed by CMS or the self-disclosure protocol managed by the HHS Office of Inspector General (OIG), the provider is considered to be in compliance with the rule.
But the final rule is not entirely positive, according to Houston-based health law attorney Michael E. Clark. Many health providers had requested clarification about the level of resources small providers are expected to devote to investigating potential overpayments. Commenters suggested CMS allow for more defined overpayment responses based on provider size and resources. The agency did not do so, saying that providers, “large and small have a duty to ensure claims are accurate and appropriate and to report and return overpayments they have received.”
Refusing to allow scalable responses is unfortunate for practices that do not have the ability to react to overpayments as robustly as larger chains, Mr. Clark said.
“The agency was unwilling to go that far,” Mr. Clark said. “They’re not going to give a lesser standard for smaller providers. They’re going to look at the facts and circumstances. It gives [CMS] subjectivity, whereas doctors would rather have more clarification and objectivity.”
On Twitter @legal_med
There is finally some clarity about how to report and return Medicare overpayments, under a final rule released by the Centers for Medicare & Medicaid Services Feb. 11.
The final regulation clarifies that health providers have identified an overpayment when they “have or should have, through the exercise of reasonable diligence, determined [they have] received an overpayment and quantified the amount of the overpayment.”
Overpayments must be reported and returned only if identified within 6 years of the date the payment was received – down from the 10 years included in the proposed rule released in 2012. Physician organizations and other health care stakeholders had criticized the proposal, calling the 10-year time frame unreasonable and burdensome.
The revised definition of identification makes more sense for physicians, particularly that identification exists when providers have quantified the amount of the overpayment, said Scot T. Hasselman, a Washington health law attorney. In many cases, it takes time to decipher how much money is owed after discovering a potential overpayment, he said in an interview.
“This all goes to: When does the clock begin ticking for the 60 days?” he said. “The language in the final rule provides for a standard that is easier to apply.
The 6-year time frame is also more reasonable and will save practices money by limiting their audit obligations, Mr. Hasselman noted.
The final rule also allows the 60-day deadline for returning overpayments to be suspended if a provider requests an extended repayment schedule. In the past, “people could be in a real pickle if they didn’t have the money to return,” Mr. Hasselman said. “This [provision] is important, especially for smaller [practices] and physicians who may not have big credit lines or the cash flow of an institutional provider.”
The final rule also clarifies how to report overpayments. Providers and suppliers must use an applicable claims adjustment, credit balance, self-reported refund, or another appropriate process to satisfy the obligation to report and return overpayments, the rule states. If a provider has reported a self-identified overpayment using the self-referral disclosure protocol managed by CMS or the self-disclosure protocol managed by the HHS Office of Inspector General (OIG), the provider is considered to be in compliance with the rule.
But the final rule is not entirely positive, according to Houston-based health law attorney Michael E. Clark. Many health providers had requested clarification about the level of resources small providers are expected to devote to investigating potential overpayments. Commenters suggested CMS allow for more defined overpayment responses based on provider size and resources. The agency did not do so, saying that providers, “large and small have a duty to ensure claims are accurate and appropriate and to report and return overpayments they have received.”
Refusing to allow scalable responses is unfortunate for practices that do not have the ability to react to overpayments as robustly as larger chains, Mr. Clark said.
“The agency was unwilling to go that far,” Mr. Clark said. “They’re not going to give a lesser standard for smaller providers. They’re going to look at the facts and circumstances. It gives [CMS] subjectivity, whereas doctors would rather have more clarification and objectivity.”
On Twitter @legal_med
