CMS proposes Quality Payment Program rule for 2018 

The Centers for Medicare and Medicaid Services has proposed a new rule for its Quality Payment Program in an effort to simplify reporting requirements with updates for the second and future years of the program.

In October 2016, CMS published a final rule to implement the Quality Payment Program (QPP) under the Medicare Access and CHIP Reauthorization Act (MACRA), designed to reward providers for value and improved health outcomes. As part of the program, clinicians have two tracks to choose from—the Merit-Based Incentive Payment System (MIPS) or the Advanced Alternate Payment Models (APMs), based on their practice size, specialty, location or patient population.

The new reimbursement approach in MACRA incorporates payments to reward providers for their use of information technology and data.

“The proposed rule would amend some existing requirements and also contains new policies for doctors and clinicians participating in the Quality Payment Program that would encourage participation in either APMs or the MIPS,” according to the agency’s June 20 announcement.

“Additionally, CMS has used clinician feedback to shape the second year (2018) of the program,” states the announcement. “If finalized, the proposed rule would further advance the agency’s goals of regulatory relief, program simplification, and state and local flexibility in the creation of innovative approaches to healthcare delivery. Moreover, CMS is making it easier for rural and small providers to participate.”

The agency says it is sensitive to stakeholder concerns that small, independent and rural practices in particular are not sufficiently prepared for the Quality Payment Program. By providing additional flexibility in its proposed rule, CMS contends that barriers will be reduced further, enhancing the ability of small practices to participate successfully.

In particular, the rule calls for an increased low-volume threshold that will exempt eligible MIPS clinicians with less than $90,000 in allowed charges or fewer than 200 Medicare Part B beneficiaries from having to participate in the program. The threshold in 2017 was $30,000 in allowed charges or fewer than 100 beneficiaries.

“We’ve heard the concerns that too many quality programs, technology requirements, and measures get between the doctor and the patient,” said CMS Administrator Seema Verma in a written statement. “That’s why we’re taking a hard look at reducing burdens.” 

When it comes to health IT, CMS proposes reduced burdens and increase flexibility to help clinicians to successfully participate in QPP by continuing to allow the use of 2014 Edition Certified Electronic Health Record Technology, while encouraging the use of 2015 edition CEHRT.

“By proposing this rule, we aim to improve Medicare by helping doctors and clinicians concentrate on caring for their patients rather than filling out paperwork,” Verma added. “CMS will continue to listen and take actionable steps towards alleviating burdens and improving health outcomes for all Americans that we serve.”

Industry groups were quick to respond to the proposed rule with praise for the agency’s flexibility, including the American Medical Association.

“CMS is proposing a number of policies to help physicians avoid penalties under the Quality Payment Program. In particular, it is suggesting several actions to assist small practices,” said AMA President David Barbe, MD. “The administration showed it heard the concerns raised by the AMA on behalf of practicing physicians.”

Barbe pointed out that “not all physicians and their practices were ready to make the leap, and many faced daunting challenges.” However, he believes that CMS’s “flexible approach will give physicians more options to participate in MACRA and takes into consideration the diversity of medical practices throughout the country.”

Likewise, Tom Nickels, executive vice president of the American Hospital Association, said AHA was “encouraged by CMS’s proposal for a facility-based clinician reporting option that may promote better alignment and collaboration on efforts to improve quality among hospitals and clinicians.”

In particular, Nickels applauded CMS’s proposal to “provide much-needed relief from unrealistic, unfunded mandates for EHR capabilities by extending the use of modified Stage 2 Meaningful Use requirements through 2018,” and he encouraged the agency to “provide the same relief to hospitals.”

AHA also encouraged CMS to provide additional opportunities for clinicians to earn incentives for partnering with hospitals to provide better quality, more efficient care through advanced alternative payment models.

“We will review the details of the proposed rule and will provide input to the agency to help ensure CMS’s polices enable patients to benefit from the transformation of care envisioned by MACRA,” Nickels concluded.

CMS will accept comments on the proposed rule until 5 p.m. on August 21. However, not all industry groups responded favorably to the agency’s proposed rule.

While the American Medical Group Association said it recognizes the burden MACRA places on small practices and appreciates the options for them to participate, it said it’s concerned that the proposed rule delays the transition to value and does not recognize the investment that its members have made in preparing for a value-based healthcare system.

“If CMS wants to transition to value-based payment for care, the program needs to be fully implemented,” said Chester Speed, AMGA’s vice president for public policy. “We recommend that CMS revise its proposal to fully incentivize high performers in the Medicare program.”

Source: CMS proposes Quality Payment Program rule for 2018 | Health Data Management

Posted in Government Regulations, Industry Updates

Dr. Lawrence Weed, Pioneer in Recording Patient Data, Dies at 93

Dr. Lawrence L. Weed, who created a system for organizing patient information that is used all over the world, at a lecture in 1971. CreditVisualDX

Dr. Lawrence L. Weed, who introduced a system for organizing patient data in the 1950s that is now used in hospitals all over the world, and who led the way in developing a computerized method for aiding in the diagnosis and treatment of diseases, died on June 3 at his home in Underhill, Vt. He was 93.

His son Lincoln confirmed the death.

In the early 1950s, Dr. Weed was a professor of medicine and pharmacology at Yale, where he spent most of his time doing research on microbial genetics. On occasion, though, he would accompany students on their hospital rounds and watch as they struggled to interpret the often chaotic patient notes left by doctors.

It was a sobering experience. “I realized then — and it was very upsetting — that they weren’t getting any of the discipline of scientific training on those wards,” Dr. Weed told The Journal of the American Medical Informatics Association in 2014. “When I pick up a chart that is a bunch of scribbles, I say: ‘That’s not art. It certainly isn’t science. Now, God knows what it is.’”

He responded by creating the problem-oriented medical record, or POMR, a way of recording and monitoring patient information. Two of its features have become nearly universal in health care: the compiling of problem lists and the SOAP system for writing out notes in a patient chart. SOAP stands for subjective, objective, assessment and plan, reflecting the steps that doctors and other health care providers should follow as they move from an initial patient encounter to tests, diagnosis and treatment.

Dr. Weed presented his new method in a two-part article in The New England Journal of Medicine, “Medical Records That Guide and Teach.” Published in 1968, it is one of the most frequently cited articles in the field of medical informatics.

“Saying that POMR was revolutionary almost understates it,” Dr. Charles Safran, the chief of the division of clinical informatics at Beth Israel Deaconess Medical Center and Harvard Medical School, told The Economist in 2005. “There’s probably no one who has more fundamentally affected the way we organize our work than Larry Weed. He fundamentally changed American medicine.”

With a grant from the Department of Health Education and Welfare (now Health and Human Services), Dr. Weed developed a computerized version of POMR that came to be known as Promis — the Problem-Oriented Medical Information System.

This led him, in the 1980s, to another innovation: “knowledge coupling” software linked to a database of medical knowledge derived from thousands of journal articles. Doctors could input the information gathered in the POMR process and then receive a list of possible diagnoses and treatment options, with arguments for and against each option.

Many doctors took a dim view of Dr. Weed’s innovation, regarding it as a challenge to their professional expertise. Dr. Weed saw it as a solution to an intractable problem — the unrealistic expectation that one brain, no matter how well trained, can store and apply the medical knowledge required to make proper decisions.

“For every complaint, for chest pain or abdominal pain, there can be 50 or 60 causes, and the doctor cannot remember all of them,” he told The Boston Globe in 1987. In an interview with The Permanente Journal in 2009, he said, “An epidemic of errors and waste is occurring as we persist in trying to do the impossible.”

Lawrence Leonard Weed was born on Dec. 26, 1923, in Troy, N.Y. His father, Ralph, was a salesman. His mother, the former Bertha Krause, was a homemaker.

Lawrence, known as Larry, was a gifted pianist with a fine baritone voice, but an interest in science led him to earn a chemistry degree from Hamilton College in Clinton, N.Y., in 1945.

After receiving a medical degree from Columbia University in 1947, he took mixed internships in medicine, chest medicine, surgery and clinical pathology at University Hospital in Cleveland and Bellevue Hospital in Manhattan.

Before completing a residency at Johns Hopkins University, he did basic research in biochemistry and microbial genetics at Duke University, the University of Pennsylvania and Walter Reed Army Medical Center (now the Walter Reed National Military Medical Center) in Washington. He then accepted a double appointment at Yale in pharmacology and medicine.

In 1952 he married Laura Brooks, a fellow intern in Cleveland with a medical degree from Yale. She died in 1997. In addition to his son Lincoln, he is survived by two other sons, Christopher and Jonathan; two daughters, Dinny Adamson and Becky Weed; a sister, Nancy Weed; two granddaughters; and two stepgranddaughters.

Dr. Weed’s eagerness to bring scientific rigor to medical record keeping led him in 1956 from Yale to Bangor, Me., where he accepted an offer to direct the new medical internship and residency program at Eastern Maine General Hospital. There he worked out the concepts of POMR.

After four years he became an assistant professor of microbiology at Case Western Reserve University in Cleveland, where, beginning in 1964, he also directed the outpatient clinic of Cleveland Metropolitan General Hospital. In his spare time, he sang with the Cleveland Orchestra Chorus under Robert Shaw.

It was in Cleveland that he began working with computers to develop the Promis system, which he took to the University of Vermont in 1969, where he became professor of community medicine. In the early 1980s he left to start the Problem-Knowledge Coupler Corporation, which developed knowledge-coupling software as well as a PC-based version of the POMR. He left the company in 2006. It was acquired in 2012 by the Atlanta-based company Sharecare, whose AskMD app uses Dr. Weed’s coupling software.

Dr. Weed could be a prickly ambassador for his ideas. He was not shy about criticizing American medical education — he proposed that traditional medical schools be radically restructured — and went a few steps beyond tough love in telling doctors about their limitations.

At one medical conference, as he argued for the superiority of his computer programs over traditional medical expertise, an unhappy surgeon rose to protest. Surely, the surgeon said, experience and intuition counted for something. Dr. Weed met him halfway.

“Well, I’m not saying you don’t have intuitive feelings,” he recalled answering in The Journal of the American Medical Informatics Association. “What I’m suggesting is that they may be worthless.”

Dr. Weed was the author of “Medical Records, Medical Education, and Patient Care: The Problem-Oriented Record as a Basic Tool” (1969); “Your Health Care and How to Manage It: Your Health, Your Problems, Your Plans, Your Progress” (1975); “Knowledge Coupling: New Premises and New Tools for Medical Care and Education” (1991); and “Managing Medicine” (1993).

His last book, the polemical “Medicine in Denial” (2011), written with his son Lincoln, outlined his plan for an overhaul of medical practice, with education aimed at fostering skills rather than knowledge.

He was impatient to see changes. “People have been saying to me since the 1960s, ‘You’re ahead of your time,’” he told the journal Modern Healthcare in 2012. “I say, ‘My God, you want me to live until 160? How long are you going to take?’”

Source: Dr. Lawrence Weed, Pioneer in Recording Patient Data, Dies at 93 – The New York Times

Posted in Industry Updates, Providers Perspective

Sloppy Citations of 1980 Letter Led To Opioid Epidemic

A one-paragraph letter, barely a hundred words long, unwittingly became a major contributor to today’s opioid crisis, researchers say.

“This has recently been a matter of a lot of angst for me,” Dr. Hershel Jick, co-author of that letter, told Morning Edition host David Greene recently. “We have published nearly 400 papers on drug safety, but never before have we had one that got into such a bizarre and unhealthy situation.”

The letter, published in the New England Journal of Medicine in 1980, was headlined “Addiction Rare in Patients Treated With Narcotics.” Written by Jick and his assistant Jane Porter of the Boston Collaborative Drug Surveillance Program at Boston University Medical Center, it described their analysis of hospitalized patients who had received at least one dose of a narcotic painkiller. Among the nearly 12,000 patients they looked at, they found “only four cases of reasonably well documented addiction in patients who had no history of addiction.” Their conclusion was that despite widespread use of narcotics in hospitals, addiction was rare in patients who had no history of addiction.

“We believe that this citation pattern contributed to the North American opioid crisis by helping to shape a narrative that allayed prescribers’ concerns about the risk of addiction associated with long-term opioid therapy,” they write, pointing out that citations soared after the introduction of OxyContin in the mid-1990s.

Jick says that when the letter was published in 1980, it was almost inconsequential. “Only years and years later, that letter was used to advertise by new companies that were pushing out new pain drugs,” he says. “I was sort of amazed. None of the companies came to me to talk to me about the letter, or the use as an ad.”

He says the drug companies used his letter to conclude that their new opioids were not addictive. “But that’s not in any shape or form what we suggested in our letter.”

Asked whether he regrets having written the letter, Jick says, “The answer is, fundamentally, sure. The letter wasn’t of value to health and medicine in and of itself. So if I could take it back — if I knew then what I know now, I would never have published it. It wasn’t worth it.”

Source: Sloppy Citations of 1980 Letter Led To Opioid Epidemic, Researchers Say : Shots – Health News : NPR

Posted in Industry Updates, Opioid Epidemic, Providers Perspective

A new doctor discovers the ‘gritty’ downside of modern medicine

I arrived at the hospital, white coat and stethoscope in hand. It was my first day as a doctor, and I was filled with a nervous mix of optimism and excitement.

I walked up to the medicine team room, entered the code on the door and introduced myself to the other residents — some of them newly minted doctors like me. I was about to receive handoff from the night team for the patients assigned to me. Years of school had led up to this point. I had dreamed about this moment. I was about to care for patients as a doctor for the first time.

That’s when the realities of practicing medicine hit me like a freight train.

My computer credentials didn’t work, so I couldn’t log on to the hospital’s system. As I waited on hold with the IT department, I tried to keep up with the handoff. I needed to learn about their conditions, medications and treatment plans. Labs were waiting to be followed up. Consults had to be placed.

My pager started going off. Questions piled in from nurses, case managers, social workers and other co-workers: Is this patient being discharged today? Can you sign this disability form? Have you placed that clinic referral yet?

 I paused to collect myself and performed a ritual well known to physicians and other health-care providers. I grabbed a blank piece of paper, folded it in half and wrote down my patients’ names. Underneath each name, I began listing my checkboxes, or tasks for the day.

Before I knew it, we residents and the supervising physician were off to see patients. I had only just met some of the people whom we were going to be sending home. We wheeled computers with us, placing orders as we went from room to room. Still grappling with the unfamiliar electronic medical record used by the hospital, I could barely find the right buttons to click. The list of checkboxes on my folded paper grew and grew.

Later in the day, we all slumped back to the team room. Discharge summaries needed to be signed. Progress notes had to be written. Families wanted updates. My fellow residents and I typed away at our computers, phones to our ears, pagers ringing out.

My first day as a doctor was overwhelming, to say the least.

While medical school introduces budding physicians to the science of disease and treatment, residency trains us how to care for patients within the labyrinth of the U.S. health-care system. We have to learn how to work within hospitals and clinics with the goal of becoming independent practitioners. We come face to face with the gritty realities of insurance coverage and electronic medical records. The bureaucracy of providing patient care in many ways defines how we learn to practice.

In medical school, clinical medicine often comes down to “Drug A treats Condition Z.” During residency, we learn that A treats Z if you can figure out how to order A in the computer, you document why you chose A in your note, the hospital approves the choice of A, insurance covers A, the patient can afford A’s co-pay, you sent the prescription for A to the right pharmacy, the patient actually picks up A from the pharmacy, and you coordinate follow-up appointments to see if A is helping the patient.

As my first year of residency has gone by, I’ve become increasingly aware of how much time we dedicate to the administrative side of medicine — and the very real costs for up-and-coming physicians. I can write a comprehensive hospital discharge summary, but I can hardly place an IV in a patient. I know what a prior authorization form looks like, but I don’t know what my patients’ pills look like. I often spend 12 busy hours in the hospital but less than a few hours with my patients.

Often, it seems that administrative skills have begun to outweigh the human connection necessary between caregivers and patients.

Of course, some of these concerns are magnified during residency training. In academic medical centers, much of the grunt work of patient care, from placing orders to writing notes, falls upon residents.

But in other ways, young doctors are just scratching the surface of the health-care bureaucracy. As residents, we’re often shielded from the complexity of medical billing. We don’t yet have to grapple with establishing our own practices, maintaining staff, hospital contracts or malpractice insurance.

This is a broader problem in American medicine. A study published in 2013 found that internal medical interns spent 40 percent of their time on computers. Residents often spend more than four hours per day on documentation and electronic charting, according to several studies. A 2010 review of studies suggests hospital physicians on average spend less than one-fourth of their time directly caring for patients. In a study released last year, researchers found that doctors in clinics spent nearly two hours on desk work for every one hour with patients.

All this paperwork is straining physicians. A nationwide study found that more than 90 percent of medical residents felt the amount of required documentation in patient care was too much. In a 2016 survey of more than 6,000 doctors, half did not feel the level of clerical work in medicine was reasonable. Editorials in top journals across medicine have cited administrative workloads as part of the reason for the alarming rates of burnout in the profession.

When I look back on medical school, I remember sitting with patients for hours, chatting with them, learning about their lives. As medical students, we’re often given the time to do so, protected from the bureaucracies of medicine so we can spend time learning how to care for people. By comparison, as I reflect on my first year as a doctor, I cringe at how many days I spend sitting at computers, clicking away in windowless rooms, staring into screens, separated from patients.

I find hope in those words. My days are measured by countless checkboxes, but whenever possible I try to add just a few more — I tell myself they’ll be worth it. Go to the bedside during free moments. Check in with my patients before going home. Stop by for those chats again, even if I’m tired and it’s late.

It’s been nearly a year since that first day in the hospital. Today, I’m far more efficient as a physician. My typing has sped up, and I have templates for virtually every kind of note. I can now find orders in the computer by muscle memory. I’ve learned how to admit patients into the hospital, transfer them between units, discharge them, refer them to specialists and follow up with them in clinic.

I’m becoming better at providing health care, but does that mean I’m better at taking care of patients?

Source: A new doctor discovers the ‘gritty’ downside of modern medicine – The Washington Post

Posted in Industry Updates, Providers Perspective

Colorado Hospitals Unite to Combat Prescription Opioid Abuse

A group of doctors and administrators has come up with an ambitious plan for Colorado hospitals to reduce the amount of opioids they prescribe while still treating pain effectively, according to an article in the Denver Post. The plan will roll out this year as a six-month pilot program at eight hospitals and three freestanding emergency rooms.

Health officials hope to analyze data from the program at the three-month mark to determine what’s working best and what’s not, said Diane Rossi MacKay of the Colorado Hospital Association (CHA).

The effort is part of a broad rethinking in the medical world about the place opioids, blamed for an epidemic of addiction and overdoses, should hold in medicine, according to the Post article.

“For far too long, pain has equaled an opioid,” said Dr. Don Stader, an emergency room physician at Swedish Medical Center in Denver. “And that’s what got us into this problem.”

The Centers for Disease Control and Prevention (CDC) and state regulators across the country have issued guidelines calling on doctors to reduce their opioid prescribing. In addition, the FDA recently announced that it is seeking to remove one opioid, Opana ER (extended-release oxymorphone, Endo Pharmaceuticals), from the market because its addictive potential outweighs its medical benefit.

The new program that Stader helped put together—along with the CHA and members of the Colorado chapter of the American College of Emergency Physicians—aims to go even further by combining a number of ideas. Not only does the program encourage doctors to prescribe fewer opioids, it also provides them with condition-specific guidelines for treatments that can be used to control pain effectively without narcotics. In some cases, the guidelines might call for substituting doses of Tylenol and other medications for opioids, Stader said. In others, there are “trigger point” procedures that could work.

The plan won’t eliminate opioids in the hospital altogether, Stader said, but they aren’t the first resort in most instances.

In addition, the program calls for hospitals and emergency rooms to become front-line players in providing treatment to people with opioid addiction. Instead of telling patients to find a rehabilitation clinic first, doctors potentially could start patients on medication-assisted therapy with a drug such as buprenorphine or methadone right away. In a state survey conducted this year, people who successfully quit heroin identified such treatment as the most effective way to do so.

At the Swedish Medical Center, Stader said the hospital began implementing some elements of the program a year ago. In that time, the hospital has cut its opioid use by 30%, he said.

“Opioids now aren’t just the only drugs we use,” he said. “They’re part of a large collection of drugs that we use to control pain better.”

Source: Colorado Hospitals Unite to Combat Prescription Opioid Abuse | Managed Care Magazine Online

Posted in Industry Updates, Opioid Epidemic

New tool for overdoses: Emergency box with antidote | Lexington Herald Leader

Defibrillator boxes have become commonplace in public places as a way to help people having a heart attack. Now, a group in Rhode Island has come up with a similar idea for a different medical crisis: drug overdoses.

The NaloxBox is meant to give bystanders in public areas easy and quick access to the opioid overdose antidote naloxone. Just as with a defibrillator box, the NaloxBox puts a lifesaving intervention in the hands of a layperson.

“That person could have no training at all,” said Geoff Capraro, an emergency room doctor and faculty member at Brown University’s medical school. “I wanted to give people the ability to help their neighbor.”

Capraro worked with a group of professors and students at Rhode Island School of Design to design and build the box, and the first were installed Friday in Amos House, which provides recovery services, shelter and other programs to help people struggling with addictions.

More than 30 are set to be installed in the coming weeks at around a dozen social services organizations around Providence, said Claudia Rebola, an industrial design professor at RISD who worked on the project.

Amos House CEO Eileen Hayes said her staff has seen many overdoses, which are part of the process of recovery. The benefits of the NaloxBox are twofold, she said. It will provide quick access to naloxone, and it also sends a clear message to people being treated for addictions that they have to think about keeping themselves safe.

“We’re talking about life and death here, and we have had multiple situations and been affected by just too many deaths. We have to do whatever we can to keep people safe,” she said.

While naloxone — which can be administered via nasal spray under the brand name Narcan — is available without a doctor’s prescription in Rhode Island and other states, that requires a person to go into a pharmacy to get a dose, then carry it around with them.

If they overdose, they can’t help themselves.

That model is “insufficient,” Capraro said. The boxes provide what he calls a “public capacity.”

“We’re giving capacity that doesn’t exist,” he said.

The box holds two naloxone kits with two doses each and directions on how to use them, as well as a breathing mask to help a rescuer administer CPR. Also inside is information on how people can get their own naloxone or get treatment. The box can hold either the shot or spray form of naloxone, and opens easily with a Velcro-type strap.

When fully installed and connected to power, it will alert the owner via text message whenever it has been opened. That way, they can check it and refill it when needed. The boxes can be made for around $100 each, Capraro said.

Rebola expects the first iteration of the box will need some design changes, but they are interested for now to see how it’s used. Their hope is to eventually spread them further: to clubs, universities and other public areas.

Capraro has suggested facilities installing the box put it next to their defibrillator. He envisions some version of NaloxBox someday being one of three life-saving interventions people will see on a wall for good Samaritans to use: the defibrillator, the fire extinguisher and naloxone.

Source: New tool for overdoses: Emergency box with antidote | Lexington Herald Leader

Posted in Industry Updates, Opioid Epidemic

KARE 11 Investigates: VA denies ER payments, calls vets imprudent |

MINNEAPOLIS – Thousands of veterans every year are saddled with medical debt they shouldn’t owe – some of it even turned over to collection agencies – after trips to the emergency room.

A KARE 11 Investigation discovers it’s happening, in part, because the Department of Veterans Affairs does not consistently apply its own rules.

A Tough Night

When you are parents of a newborn, there can be a lot of sleepless nights. But for Ben and Gretchen Krause, one night last February stands out.

“It was a tough night, that’s for sure,” recalled Ben. It was the night he spent hours in a Woodbury, Minnesota emergency room.

“The idea of losing him, Ben, with a little baby here –  it was really scary,” said Gretchen, fighting back tears.

Ben says he began experiencing severe chest pain and was struggling to catch his breath.

“I felt like my chest was about to pop,” he said.

“I remember he said, ‘Something’s wrong,’” said Gretchen. “Something’s wrong!”

Fearing her husband was having a heart attack, Gretchen grabbed the baby out of bed and drove the family to the emergency room at HealthEast’s Woodwinds Hospital. They spent the next nine hours there.

Doctors determined that instead of a heart attack, Ben was having an extreme form of stress likely exacerbated by a recent death in the family.

“Technical term for it is malignant hypertension with neurological and cardiovascular complications,” Ben explained. “I couldn’t dial back the stress from what was going on in the grief process.”

As a service-connected disabled veteran, Ben expected the Minneapolis VA would automatically pick up the $6,066 hospital bill.

He was mistaken.

The Prudent Layperson Denial

“I got a letter in the mail saying they were going to deny me,” said Ben.

Ben’s case raises the question, just what does the VA believe is a prudent layperson’s definition of an emergency?

To find an answer, KARE 11 looked to the VA’s Prudent Layperson Fact Sheet.

The letter, which appears to be a boilerplate form, said Ben was being denied reimbursement for his visit to Woodwinds Health Campus because, “The treatment provided does not meet the Prudent Layperson definition of an emergency.”

“Apparently, a prudent normal guy wouldn’t have gone to the emergency room if they were experiencing chest pains,” exclaimed Ben sarcastically. “A normal layperson would have just sat on the couch, I guess.”

The Fact Sheet describes a prudent layperson as someone:

“… possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to obtain immediate medical care could result in placing the patient’s health in serious jeopardy, cause serious impairment to bodily functions, serious dysfunction of any bodily organ or part, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy.”

Gretchen Krause maintains she and her husband did what anyone would have done when facing a similar situation.

“I’m not a doctor, I’m not a nurse,” she explained. “I know when to go to the ER. You go to the ER when someone is in distress, and he was in distress!”

While many veterans might have concerns about challenging the VA denial, Ben Krause happens to be one of the nation’s most prominent and outspoken veteran’s rights attorneys.

Ben likens the VA’s letter to bad faith insurance denials. “This is straight out of the insurance company 101 books on how to deny a claimant,” he said.

In fact, KARE 11 discovered the VA’s own guidelines spell out an example of when a veteran was acting prudently when they visited an emergency room – even if the final diagnosis turns out to be something less serious.

“Case Example A” describes a patient who goes to the ER complaining of chest pain but is given a diagnosis of “mild gastric irritation.”

The VA’s “Prudent Layperson Fact Sheet” goes on to state that because chest pain is a “potentially serious problem” it “clearly falls into the category of what any prudent layperson would consider an appropriate use of an emergency department.”

“When you look at it this, it is almost verbatim your case,” KARE Investigative Reporter A.J. Lagoe said to Krause while reading the VA Fact Sheet.

“Right,” Krause laughed. “It’s black and white and it is Case Example A!”

“This is spot on exactly what I experienced,” Krause said. “Chest pains, going to the emergency room. I’m not a doctor! How am I going to know whether I’m truly having a heart attack or not?”

Systemic Pattern

KARE 11 wanted to know, is Krause’s case an isolated problem, or a systemic pattern of dubious denials?

“If it happened to me, I guarantee it’s happening to thousands of veterans nationwide,” Krause said.

He is right.

During a Congressional hearing last year, VA Assistant Deputy Undersecretary for Health for Community Care, Dr. Baligh Yehia submitted written testimony about veterans being denied payment for emergency room visits.

That statement shows between the beginning of fiscal year 2014 and August of 2015, approximately 98,000 claims were denied because the condition was determined not to be an emergency.

Dr. Yehia wrote, “Many of these denials are the result of inconsistent application of the ‘prudent layperson’ standard from claim to claim and confusion among Veterans about when they are eligible to receive emergency treatment through community care.”

He added, “When denied, the financial responsibility for these claims, which can be substantial, often falls on Veterans…”

“It’s absurd,” said Krause who wrote about his imprudent layperson denial on his popular veteran’s blog.

In his article, he served notice to the VA he was working with KARE 11 to get to the bottom of his claim denial.

VA Reversal

The same day KARE 11 emailed the Minneapolis VA asking for an interview to discuss the case, Krause says he received a call from an official saying a mistake had been made and his claim should not have been denied.

“The second that they realized that somebody was looking into it, and somebody with the ability to make it into a national story, once they realized that, then they called and said, ‘Oh sorry, we made a mistake, we’re going to take care of it.’”

Minneapolis VA officials refused to be interviewed for this report.

However, in an email they blamed the denial on a “coding error” by the non-VA emergency room that treated Krause. They also stated that at the time of the initial denial, VA did not yet have all his records.

It appears the denial letter was issued without anyone at the VA contacting either the private hospital or Krause to determine the nature and cause of his hospital visit.

The VA spokesman confirmed that Krause’s entire claim for emergency medical care is now being covered.

Even so, Krause questions how many other veterans have the ability to quickly get the VA’s attention without going through the appeals process, which often takes up to five years.

“If you don’t have the ability to get your story out there,” he said, “I mean, you’re not going to get the justice you need.”

Source: KARE 11 Investigates: VA denies ER payments, calls vets imprudent |

Posted in ER Billing, Industry Updates

Shakopee hospital using acupuncture in emergency room |

SHAKOPEE, Minn. – Minnesota hospitals are blazing a trail when it comes to integrative medicine. Only two hospitals in the nation offer acupuncture in the emergency room.

St. Francis Regional Medical Center started practicing the traditional Chinese medicine in its emergency room in April, following Abbott Northwestern’s lead.

A recent study by the Penny George Institute for Health and Healing found that ER patients who receive acupuncture experience significant reductions in pain and anxiety.

St. Francis is using acupuncture to treat symptoms such as migraines, nausea, anxiety and pain.

”We find out what it is that patients need that works along with Western medicine,” said Kristianne Schultz, Licensed Acupuncturist at St. Francis.

St. Francis officials say they hope acupuncture will replace opioid prescriptions for many patients. They say 91 Americans die every day from an opioid overdose.

Source: Shakopee hospital using acupuncture in emergency room |

Posted in Industry Updates, Opioid Epidemic

Express Scripts takes stab at reducing opioid abuse | St. Louis Public Radio

St. Louis-based pharmacy benefits management company Express Scripts is tackling the opioid crisis.

The company announced an initiative Wednesday to more than 600 clients gathered in Dallas for an annual Express Scripts conference. The program focuses on limiting exposure to the painkillers and gives patients access to specialty-pharmacists to make sure the drugs are used properly.

St. Louis-based Express Scripts has announced a new initiative to combat opioid abuse.
The initiative follows a pilot study that produced a roughly 40percent drop in hospitalizations and emergency room visits by new patients, according to Express Scripts spokesperson Brian Henry. He said there was also a significant drop in the need for more opioids.

“And that’s important. Because when you are done with your treatment and your pain is resolved. If you got extra pills and you start taking those extra pills you’re more likely to become addicted to pills.” Henry said.

The initiative is designed for people who are prescribed opioids for the first time.

“If you can keep somebody from being addicted in the first place, that’s where you can have the greatest impact,” Henry told St. Louis Public Radio. “And that really is where Express Scripts is putting this program together – is focusing on that initial touchpoint for people who are new to treatment to make sure they get the medicine they need, and don’t get more medicine than they need that could cause them to eventually become addicted.”

Express Scripts says more than 1,000 people a day in the U.S. are treated in emergency rooms for abusing prescription opioids.

Source: Express Scripts takes stab at reducing opioid abuse | St. Louis Public Radio

Posted in Industry Updates, Opioid Epidemic

New Johns Hopkins Study Suggests People Who Visits Emergency Rooms Are Often Overcharged | Town of Morningside Maryland

Study Shows Emergency Room Patients Are Often OverchargedA new study conducted by Johns Hopkins University School of Medicine revealed that in emergency rooms throughout the United States, people are overcharged for treatments and services. In fact, those people are charged on average 340 percent more than the Medicare allowable amount. The people who bear the brunt of the overcharges include those who are uninsured and minorities.

The study demonstrates that more transparency is needed in hospitals to ensure all patients are charged the same amount for treatments and services.

“There are massive disparities in service costs across emergency rooms and that price gouging is the worst for the most vulnerable populations,” Martin Makary, a professor at Johns Hopkins School of Medicine. “Our study found that inequality is then further compounded on poor, minority groups, who are more likely to receive services from hospitals that charge the most.”

The research team analyzed 2013 medical billing records for a total of 12,337 emergency room physicians in approximately 300 hospitals located in all 50 states. Those records were then cross-referenced with the 2013 American Hospital Association database to verify the actual regional location, size and other important details – teaching status, for-profit status and rural/urban status – of each emergency department. The Medicare allowable amount, the total amount paid by Medicare for a specific procedure or service, and costs billed to the patients were also compared.

The findings revealed that between the Medicare allowable amount and charges billed to the patients was known as the markup ratio. For example, a markup ratio of 4.0 for a procedure with a Medicare allowable amount of $100, the patient would be charged $400 by the hospital, which is 300 percent more than the Medicare allowable amount.

The research team discovered emergency medicine physicians had a markup ratio on average of 4.4, when compared to the Medicare allowable amount, which resulted in 340 percent more in charges. The emergency departments located in for-profit hospitals and in the Midwestern and southwestern United States were more likely to charge patients the most, as well as serve populations of uninsured Hispanic and African-American patients. The greatest median markup ratio at 7.0 was for wound closure services. The service that had the greatest in-hospital variation was the interpretation of head CT scans, which had a markup ratio between 1.6 and 27 in just one hospital.

“This is health care systems problem that requires state and federal legislation to protect patients,” says Tim Xu, a medical student at Johns Hopkins Hospitals. “Patients really have no way of protecting themselves from these pricing practices.”

The study was published online in JAMA Internal Medicine on May 30, 2017.

Source: New Johns Hopkins Study Suggests People Who Visits Emergency Rooms Are Often Overcharged | Town of Morningside Maryland

Posted in ER Billing, Industry Updates