texas family physician VOL. 63 NO. 2 SPRING 2012
Texas Medical Board Rules You Should Know Manage Your Risk: Review The Closed Claim Study Inside CMS Announces New Measures To Target Fraud And Abuse News And Pics From TAFP’s 2012 C. Frank Webber Lectureship
Recovery Audit Contractors
PREPARE TO DEFEND YOUR CODING
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INSIDE
20 TEXAS FAMILY PHYSICIAN VOL. 63 NO. 2 SPRING 2012
20
16 MEMBER NEWS Family physicians gather to learn, network at TAFP symposium | Members to study health care efficiency | TAFP Foundation awards grants and scholarships
Prepare to defend your coding
Family physicians face increased scrutiny in medical coding and documentation under the recovery audit contractor program, Medicare’s effort to curtail fraud, waste, and abuse. Learn what the auditors are looking for and how to prepare for an inevitable audit. By Kate Alfano
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Four TMB rules you should know
TMLT presents the first of a two-part series on Texas Medical Board rules physicians may unknowingly break, starting with physician advertising, leaving a medical practice, documentation, and prescribing.
28 RISK MANAGEMENT Follow a TMLT malpractice case from start to finish for techniques that can increase your defensibility. 30 NUTRITION New school meal standards increase access to nutrientdense foods.
By TMLT Risk Management Department
12
CMS to expand audit authority
New RAC demonstrations target power mobility device prescribing and test pre-payment audits.
14
AAFP to RUC: Proceed cautiously
AAFP will continue participation in the RUC, but acknowledges that changes must and will be made. 4
[SPRING 2012]
TEXAS FAMILY PHYSICIAN
6 PRESIDENT’S LETTER Among other roles, physicians must be protectors and comforters. 8 NEWS CLIPS Paying more for primary care would yield Medicare savings | Obesity rates level off in U.S. | Health insurance by the numbers | Family docs most likely physicians to serve rural areas
33 RESEARCH Researchers explore changes in the complexity of ambulatory care across disciplines. 37 INTERIM SESSION MINUTES IN BRIEF See the latest actions taken by the TAFP Board of Directors. 38 PERSPECTIVE Physicians must learn to provide a medical home for every patient, every day.
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president’s column
TEXAS FAMILY PHYSICIAN VOL. 63 NO. 2 SPRING 2012 The Texas Academy of Family Physicians is the premier membership organization dedicated to uniting the family doctors of Texas through advocacy, education, and member services, and empowering them to provide a medical home for patients of all ages. Texas Family Physician is published quarterly by TAFP at 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Contact TFP at (512) 329-8666 or jnelson@tafp.org. Officers president
I. L. Balkcom IV, M.D.
president-elect
Troy Fiesinger, M.D.
vice president treasurer
Dale Ragle, M.D.
Clare Hawkins, M.D.
parliamentarian
Ajay Gupta, M.D.
immediate past president
Melissa Gerdes, M.D.
Editorial Staff managing editor
Jonathan L. Nelson
associate editor
Kate Alfano
chief executive officer and executive vice president
Tom Banning chief operating officer
Kathy McCarthy, C.A.E.
advertising sales associate
Audra Conwell
Contributing Editors David W. Bauer, M.D. Carlos R. Jaén, M.D., Ph.D. David A. Katerndahl, M.D., M.A. TMLT Risk Management Department Teresa Wagner, M.S., R.D./L.D. Robert Wood, Dr. P.H. subscriptions To subscribe to Texas Family Physician, write to TAFP Department of Communications, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Subscriptions are $20 per year. Articles published in Texas Family Physician represent the opinions of the authors and do not necessarily reflect the policy or views of the Texas Academy of Family Physicians. The editors reserve the right to review and to accept or reject commentary and advertising deemed inappropriate. Publication of an advertisement is not to be considered an endorsement by the Texas Academy of Family Physicians of the product or service involved. Texas Family Physician is printed by The Whitley Company, Austin, Texas. legislative advertising Articles in Texas Family Physician that mention TAFP’s position on state legislation are defined as “legislative advertising,” according to Texas Govt. Code Ann. §305.027. The person who contracts with the printer to publish the legislative advertising is Tom Banning, CEO, TAFP, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. © 2012 Texas Academy of Family Physicians postmaster Send address changes to Texas Family Physician, 12012 Technology Blvd., Ste. 200, Austin, TX 78727.
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[SPRING 2012]
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Protecting our most vulnerable By I. L. Balkcom IV, M.D. TAFP President her name was not important. This little 6-year-old girl I had been called to examine in the emergency room now sat silently, flanked by her mother and mother’s boyfriend. I was in my third year of residency and was summoned to evaluate this patient who I’d been told had fallen in the bathtub at home. She had a large bruise around her left eye. As I entered her exam room with my interns in tow, I was immediately struck by the defiant posture of the mother and apparent lack of concern by the boyfriend. Yes, physicians are often very suspicious. All questions were answered, not by the child, but by the adults. Her mother stated that the child had slipped and fallen in the bathtub, striking her eye on the cold water handle. Why was the bruise so perfectly round? Why was it so large? Why wouldn’t the child talk to me? Was she frightened by the giant in the white coat? Under pretense of taking the child to X-ray, we did a complete exam and found the sickening evidence of large bruises across her back and buttocks and between her legs. When I was able to speak to the child alone, I asked, “Who did this to you?” The small, blonde, fragile angel with a battered eye whispered softly, “Daddy.” We have, in our country, a problem as serious as any cancer or drug addiction—child abuse and neglect—and yet many cases go unreported.
Child abuse includes any maltreatment of children or adolescents by parents, guardians, or other caretakers. The most common types of abuse and neglect are physical (80 percent), sexual (15 percent), and underfeeding (5 percent). During childhood, 1 to 2 percent of all children in the U.S.A. are abused. Nearly 2,000 children die each year because of physical abuse. Especially frightening is the fact that the abuser in 90 percent of the cases is a relative. More than five children die every day as a result of child abuse and it occurs at every socioeconomic level, across ethnic and cultural lines, within all religions, and at all levels of education. Physicians have three responsibilities in child abuse cases. They must be able to detect cases, report them, and prevent future cases. The law requires physicians to report abuse to the Department of Family and Protective Service within 48 hours of suspecting abuse or neglect, and protects them from liability if their suspicions are unfounded. What can you do? If you suspect a child is being abused, bring this to the attention of DFPS. If deemed life threatening, contact your local law enforcement agency. As I sat that night by the little girl’s bed rocking her to sleep, I felt all the rage and anger toward this man who had beaten this little girl. I did what any hardened physician, accused of having no feelings, dealing with life and death daily would do—I cried. Good health to you!
Physicians have three responsibilities in child abuse cases. They must be able to detect cases, report them, and prevent future cases. The law requires physicians to report abuse to the Department of Family and Protective Service within 48 hours of suspecting abuse or neglect, and protects them from liability if their suspicions are unfounded.
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news clips
HHS announces possible delay in ICD-10 deadline
The percent of the work day primary care physicians spend on care management tasks that are mostly unpaid. Source: “Patient Care Outside of Office Visits: A Primary Care Physician Time Study.” Journal of General Internal Medicine, January 2011
Should all procrastinators rejoice? HHS Secretary Kathleen Sebelius has announced that the agency intends to delay implementation of the International Classification of Diseases, 10th Edition, the code set for outpatient diagnosis coding. The final rule adopting ICD-10 set a compliance date of Oct. 1, 2013, two years delayed from the deadline initially specified in the proposed rule. HHS will initiate a process to postpone the date by which certain health care entities have to comply with ICD-10, Sebelius said in a Feb. 16 HHS release. “We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead. We are committing to work with the provider community to re-examine the pace at which HHS and the nation implement these important improvements to our health care system.” Acting CMS Administrator Marilyn Tavenner told reporters in February that CMS will “re-examine the time frame” for ICD-10 implementation through a rule-making process, though she did not say when the rule-making process will begin. Kent Moore, manager of health care financing and delivery systems for the American Academy of Family Physicians, wrote in a post published March 5 on TAFP’s blog that a potential delay shouldn’t stop physicians’ current course of action. “Pending answers to those questions in the form of a posting in the Federal Register, physician practices are probably best advised to continue preparing for implementation on Oct. 1, 2013. Like the Boy Scouts, it is better to be prepared, lest the anticipated delay does not come to fruition.”
10
2 will get you
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Paying 10 percent more for primary care would yield a 2 percent drop in Medicare costs,
Tale of the tape The prevalence of obesity in the United States leveled off, showing no significant increases in 2009-2010 compared with figures from 20032008 for adults and 2007-2008 in children and adolescents. The ageadjusted prevalence of obesity was roughly 35 percent for men and women overall, 9.7 percent in infants and toddlers, and 16.9 percent for those aged 2-19 years. However, statistically significant increases were seen in certain populations such as non-Hispanic black women and Mexican American women, and men experienced a significant increase in body mass index over 12 years. Source: U.S. Centers for Disease Control and Prevention 2009-2010 National Health and Nutrition Examination Survey
according to a new report by the Commonwealth Fund. “These findings suggest that, under reasonable assumptions, promoting primary care can help bend the Medicare cost curve,” the authors wrote. Source: “Paying More for Primary Care: Can It Help Bend the Medicare Cost Curve?” Commonwealth Fund, March 2012
TEXAS FAMILY PHYSICIAN
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TEXAS MEDICAID BY THE NUMBERS
news clips
73.4%
TEXAS MEDICAID & CHIP AS OF SEPTEMBER 2011
of beneficiaries to Texas Medicaid and CHIP are children.
CHIP 549,581
As of September 2011, the Texas Health and Human Services Commission reports that almost 2.5 million chilPOOR PARENTS 137,078 dren were enrolled in Texas TEMPORARY Medicaid.
DISABLED 436,237
MEDICAID CHILDREN 2,499,887
ELDERLY 368,373
ASSISTANCE FOR NEEDY FAMILIES (TANF) PARENT 137,078
Source: “Texas Health Care 2011: What Has Happened and the Work that Remains.” Center for Public Policy Priorities, December 2011
MATERNITY 90,426
1 in 4 Texans is uninsured.
TEXAS HEALTH INSURANCE COVERAGE
In 2010, 44 percent of Texans received coverage through an employer, while 16 percent were insured through Medicaid, 9 percent through Medicare, and 4 percent in the individual market.
Source: American Lung Association 2012 State of Tobacco Control report card
25% 1%
44% 9%
In 2010, children accounted for 35 percent of Texas Medicaid expenditures while the elderly and disabled accounted for 55 percent of Medicaid costs.
TEXAS MEDICAID AND ACA
16% UNINSURED
4% U.S. HEALTH INSURANCE COVERAGE
Texas spent $657 less per Medicaid enrollee than the national average in 2008.
1%
16%
AVERAGE STATE MEDICAID SPENDING PER BENEFICIARY, 2008
$4,574
TX
$4,667
IL
$4,714
US
5%
$5,706
OH
$5,918 $6,937
PA
$7,020
MA
$7,985
NJ
$9,057
NY $4,000
$6,000
Source: “Texas Health Care Landscape.” Kaiser Family Foundation, November 2011 [SPRING 2012]
MEDICARE
Bad habits = bad health
16%
$5,342
NC
10
MEDICAID
49%
$3,367
FL
$2,000
INDIVIDUAL
Should federal health reform withstand court challenges, the Affordable Care Act will extend Medicaid coverage to between 1.8 million and 2.5 million new enrollees by 2019 at a total cost of $55.2 billion to $66.6 billion. The federal government will foot most of the bill, 95 or 93 percent, or $52.5 billion to $62 billion. Source: “Texas Health Care Landscape.” KFF, Nov. 2011
13%
0
EMPLOYER
OTHER PUBLIC
Source: “Texas Health Care Landscape.” Kaiser Family Foundation, November 2011
CA
Texas received a failing grade in the American Lung Association’s 2012 State of Tobacco Control report card, flunking tobacco control and spending, smoke-free air, and tobacco cessation. Texas received a D for having a cigarette tax of $1.41 per pack of 20. The Lung Association cited the 82nd Texas Legislature’s failure to pass the statewide smoking ban, but praised the Legislature for adding some coverage for tobacco cessation services for state employees. The association also praised the smoke-free efforts in many Texas cities; 36 have comprehensive ordinances in place that protect nearly half of Texans from secondhand smoke.
TEXAS FAMILY PHYSICIAN
$8,000
$10,000
Nearly two-thirds of big employers say their biggest obstacle to keeping health benefits affordable is their employees’ poor health habits, and have turned to financial incentives like cash rewards or premium rebates to persuade workers and their families to adopt healthier behaviors. The typical company offers a maximum of $300 for an individual and $700 for a worker and family combined for meeting certain health targets. An additional 20 percent say they plan to implement incentives by 2013. Further holding employees accountable, 20 percent of companies use penalties like higher premiums or deductibles if workers do not complete health management programs, and employees’ share of health premiums is expected to increase to almost $2,800. Source: Survey, Towers Watson and the National Business Group on Health
Family physicians are the most likely physicians of any specialty to practice in rural areas, with 11.1 percent of family physicians practicing in large rural areas, 7 percent in small rural areas, and 4.2 percent in isolated rural frontier areas. This compares with general internists at 6.7 percent, 2.4 percent, and 1.1 percent, respectively, and general pediatricians at 6.2 percent, 1.8 percent, and 0.8 percent, respectively. Source: Agency for Healthcare Research and Quality
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[SPRING 2012]
11
news briefs
CMS announces measures to target Medicare fraud and abuse New demonstrations to test pre-payment RAC review and prior authorization of power mobility devices By Kate Alfano the centers for medicare and medicaid services announced two new demonstration programs to target some of the most common factors that lead to fraud, waste, and abuse in Medicare. According to a CMS press release, “reductions in improper payments will help ensure the sound future of the Medicare trust fund and protect Medicare beneficiaries who depend on it.” Both will start on or after June 1, 2012. The Recovery Audit Prepayment Review demonstration allows recovery audit contractors, or RACs, to review fee-for-service claims that historically result in high rates of improper payment before they are paid to ensure compliance with Medicare payment rules. This is a clear departure from the current RAC program in which the audit contractors identify errors post-payment and follow steps to recover payment. The prepayment review will roll out in seven states “with high populations of fraud- and error-prone providers,” including Texas, and four additional states with high claims volumes of short hospital stays. RACs will conduct prepayment complex medical reviews based on data analysis of improperly submitted claims, national or local claims data, beneficiary complaints, or other data. They may also collect additional documentation, including clinical evaluations; consultations; progress notes; medical records from the physician, hospital, nursing home, or home health agency; and test reports. CMS and its agents could request supporting documentation “on a routine basis” in cases where medical necessity is unclear or there is suspicion of fraud. Kim Ross, a public affairs consultant for TAFP who specializes in health care policy and political strategy, wrote in a memo that the demonstration project expands the authority of the RACs far beyond their initial purpose: They were established by Congress to identify overpayments and underpayments and recoup overpayments, not determine medical necessity. He said it eliminates the protections granted to physicians and suppliers and allows the RACs to prevent initial payment. “This would have the effect of drastically curtailing cash flow for providers and suppliers already coping with decreased payments and allowables. Being selected by a RAC on a prepayment basis with no defined standards governing the collection and review of the paperwork for each claim would be disastrous to any company subject to a RAC prepayment review under this demonstration project.” The second demonstration, Prior Authorization for Certain Medical Equipment, establishes a prior authorization program for power mobility devices. It involves seven states, again including Texas, which submit 43 percent of power mobility device claims. CMS says the auditors will ensure that the beneficiary’s medical condition warrants the medical equipment and ensure that the beneficiary has access to quality products from accredited suppliers. 12
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TEXAS FAMILY PHYSICIAN
The demonstration will roll out in two phases. During the first, lasting a maximum of nine months, the Medicare administrative contractors will conduct prepayment reviews on the claims—that’s Trailblazer Health Enterprises in Texas. The second phase implements a prior authorization process used by private-sector payers to prevent improper payments and deter fraud. As described in a supporting statement, CMS proposes that the physician or the supplier submit a prior authorization request with “appropriate documentation” to the MAC, then the contractor confirms or denies coverage of the item and notifies the physician and beneficiary of the decision. Though CMS has not strictly defined what could be considered sufficient documentation to show medical need, it could include progress notes, diagnostic findings, or medications—all to help the MAC “create a longitudinal clinical picture of the patient.” If the paperwork is deemed incomplete, the physician or supplier has the option to resubmit the request. Detractors have criticized the paperwork burden placed on physicians, saying that it is an attempt to minimize payment under complex medical necessity determinations, not target fraud. With potential submissions and resubmissions, the process could also result in unnecessary delays of care. Without an official template for the required face-to-face examinations, TAFP developed a clinical guide and accompanying video for evaluating a patient for a power mobility device to help family physicians conform with Medicare’s extensive documentation requirements. Go to Prescribing Practices page of the Practice Resources section of www.tafp.org to access these tools.
“This would have the effect of drastically curtailing cash flow for providers and suppliers already coping with decreased payments and allowables. Being selected by a RAC on a prepayment basis with no defined standards governing the collection and review of the paperwork for each claim would be disastrous to any company subject to a RAC prepayment review under this demonstration project.” Kim Ross
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news briefs
AAFP Board decides to continue participation in the RUC the verdict is in. AAFP will continue participation in the AMA/Specialty Society Relative Value Scale Update Committee, better known as the RUC—at least for now. During the March meeting of the AAFP Board of Directors, leaders evaluated the RUC’s response to a set of demands the Academy presented in June 2011 that would change the committee’s structure, process, and procedures. “We believe, at this point, that maintaining this policy continues to best serve our members and the millions of patients they serve,” AAFP Board Chair Roland Goertz, M.D., M.B.A., wrote in a March 2012 letter. The RUC acts as an expert panel and makes recommendations to the Centers for Medicare and Medicaid Services on the relative values of CPT codes. AAFP and family physicians around the country have expressed concern that the actions of the RUC are biased toward subspecialist procedures rather than preventive care and chronic disease management, leading to an undervaluation of primary care services.
In June 2011, AAFP asked that the RUC add four “true” primary care seats, create three new seats to represent outside entities such as consumers and health plans, add an additional seat to represent geriatrics, eliminate three rotating subspecialty seats, and implement voting transparency. RUC Chair Barbara Levy, M.D., responded in February 2012 that the RUC will “add additional primary care expertise and transparency measures to our structure and processes” by adding one new primary care rotating seat and a permanent seat for geriatrics, and by adopting a policy to record RUC votes and publish a total vote count after the publication of each Medicare physician payment schedule final rule. Goertz responded in the March letter that the Academy is “deeply disappointed” that the majority of the requests were not accepted: only one primary care seat was added, the three rotating subspecialty seats were not eliminated, no seats for external representatives were added, and the voting transparency
“falls well short of full transparency to those who vote.” AAFP has pledged to advocate from within and publicly for the RUC to make necessary changes to its policies and procedures, continually reassess the Academy’s involvement on a yearly or more frequent basis, and explore other methods by which AAFP can invest in aggregating data to support initiatives that value primary care. “While we intend to present such data to the RUC as appropriate, let me also make it clear that the AAFP intends to also submit such data directly to the Centers for Medicare and Medicaid Services on a regular basis as it considers the Medicare Physician Payment Rule annually,” Goertz wrote. “No longer will the RUC be the only avenue for seeking to address the inequities in the current RBRVS system of FFS payment. In fact, over time, it is highly likely that the RUC will be but one of a much larger number of avenues for achieving payment reform leading to different and better payment for primary care services (including FFS) which are essential to a health care system meant to improve the quality and cost-efficiency of care to the American people.”
“While we intend to present such data to the RUC as appropriate, let me also make it clear that the AAFP intends to also submit such data directly to the Centers for Medicare and Medicaid Services on a regular basis as it considers the Medicare Physician Payment Rule annually.” Roland A. Goertz, M.D., M.B.A.
The latest on the SGR: Payment rate extended through 2012 Congress averted the Medicare physician payment cut that was set to take effect March 1 by passing another short-term Medicare physician payment solution. The current law extends the payment rate until the end of 2012. On Feb. 17, both the House and Senate passed H.R. 3630, which provides a 10-month extension of the current Medicare physician payment rate. Passage of the measure, which also addressed tax relief and unemployment ben-
14
[SPRING 2012]
efits, blocked a 27.4 percent Medicare payment reduction that was scheduled to take effect on March 1 as a result of the sustainable growth rate formula. Because H.R. 3630 postpones but does not eliminate the threat posed by the SGR, physicians will face a 32 percent Medicare payment reduction when the payment patch expires at the end of this year. Congress passed a two-month Medicare payment patch in late December, after which a
TEXAS FAMILY PHYSICIAN
House and Senate conference committee went to work to reconcile differences in House and Senate bills that would extend the Medicare payment rate and other provisions beyond the Feb. 29 cutoff. The conference committee agreed to the 10-month extension, which then was approved by Congress. AAFP expressed deep disappointment and concern for Congress failing to approve a long-term Medicare physician payment solution and opting
instead to settle for another short-term payment patch. In a prepared statement, AAFP President Glen Stream, M.D., M.B.I., of Spokane, Wash., said, “Congress has missed an important opportunity to permanently solve the Medicare physician payment crisis, ensure health security for elderly and disabled Americans, and enable physicians to develop the long-term plans needed to redesign their practices into patient-centered medical homes.”
CMS announces next stage for providers adopting electronic health records the centers for medicare and Medicaid Services announced the proposed rule for the second stage of the federal electronic medical record incentive program. Stage two of meaningful use requires those participating in the Medicare and Medicaid EHR Incentive Programs to use their EHR technology to meet tougher quality objectives and coordinate patient care with other physicians and health care providers. This is the second of three stages of meaningful use that physicians are required to meet to earn EHR incentives through the Medicare or Medicaid programs. The incentive program was put in place in February 2009 by the multibillion dollar American Recovery and Reinvestment Act. To be eligible for incentive funds—up to $44,000 over five years from Medicare or $63,750 over six years from Medicaid—physicians must show that they are “meaningful users” of EHR technology, beginning with basic criteria and adding capabilities over several years. Stage one began in 2011 and requires physicians to demonstrate that they can transfer data to EHRs and share information, including electronic copies and visit summaries of patients. According to a Feb. 24 CMS press release, to date, over 43,000 providers have received $3.1 billion to help make the transition to electronic health records, with additional gains for hospitals. “We know that broader adoption of electronic health records can save our health care system money, save time for doctors and hospitals, and save lives,” said Health and Human Services Secretary Kathleen Sebelius in the CMS release. “We have seen great success and momentum as we’ve taken the first steps toward adoption of this critical technology. As we move into the next stage, we are encouraging even more providers to participate and support more coordinated, patient-centered care.” Under the proposed rule, stage two would begin in 2014. It expands meaningful use to
include online access for patients to their health information and furthers the exchange of clinically relevant electronic health information between physicians and other providers. It also increases the number of core objectives that must be met. Under stage one, physicians were required to meet all of the core objectives, or qualify for exclusion, and meet five out of the 10 menu measures. Under stage two, physicians must meet 17 core objectives, or qualify for an exclusion, and meet three of five menu objectives. “The proposed rules for stage 2 for meaningful use and updated certification criteria largely reflect the recommendations from the Health IT Policy and Standards Committees, the federal advisory committees that operate through a transparent process with broad public input from all key stakeholders. Their recommendations emphasized the desire to increase health information exchange, increase patient and family engagement, and better align reporting requirements with other HHS programs,” said Farzad Mostashari, M.D., Sc.M., national coordinator for health information technology, in the CMS release. “The proposed rules announced today will continue down the path stage one established by focusing on value-added ways in which EHR systems can help providers deliver care which is more coordinated, safer, patient-centered, and efficient.” Stage three is scheduled to be implemented in 2016 and would expand meaningful use further to include demonstrating that quality has been improved. Physicians who fail to adopt EMR systems and demonstrate meaningful use criteria by 2014 may face reduced Medicare payment starting in 2015. AAFP is reviewing the 132-page proposal and will provide comments within the 60day comment period. The Academy encourages family physicians to provide input through AAFP Connection as they develop comments about the proposed federal regulations.
Start Saving Money on Vaccines Now! Discounts on Vaccines • Reimbursement Support With Payers • Timely Updates About New Products, Changes & Sales • Donations to TAFP With Every Purchase! Atlantic Health Partners is a free vaccine purchasing program open to any physician practice. Through Atlantic, your practice orders directly from manufacturers and receives discounts on a range of vaccines – infants to adults – Tdap to HPV. Atlantic also works as an advocate – working directly with payers on issues such as payment for vaccines and administration. They can provide a number of resources on billing, coding, pricing and inventory management. The program is free to your practice, and enrollment is completely voluntary. The Texas Academy of Family Physicians is partnering with Atlantic Health Partners because Atlantic can save family physicians money, advocate for fair payment and support family medicine. Atlantic Health Partners will donate 10 percent of revenue from all TAFP member sales to TAFP and provide an additional $1,000 unrestricted educational grant to the TAFP Foundation for every 125 TAFP members registered. Contact Cindy Berenson or Jeff Winokur at (800) 741-2044 or info@atlantichealthpartners.com for more information and to register.
www.tafp.org
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News from the 2012 C. Frank Webber Lectureship
Family physicians gather to expand clinical knowledge, advance the specialty more than 400 physicians, residents, and medical students gathered at the Omni Austin Hotel at Southpark to attend this year’s C. Frank Webber Lectureship and Interim Session, March 1-3, 2012. In addition to CME lectures and TAFP business meetings, the busy weekend included an ABFM SAM Group Study Workshop and the 2012 Texas Conference of Family Medicine Residents and Students. TAFP continued interacting with members through social media outlets Facebook and Twitter. View the series of tweets from the conference at www.twitter.com/txfamilydocs or enter our hashtag—#TAFP—in the search box at the top of your Twitter browser. TAFP’s SAM Group Study Workshop was held Thursday, providing an opportunity for diplomates of the American Board of Family Medicine to get credit for the Self-Assessment Module portion of their Maintenance of Certification. Attendees discussed preventive care and completed the 60-question knowledge assessment portion of the module. Attendees were then eligible to complete the clinical simulation online to receive full credit. 16
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The lectureship on Friday featured CME topics mirroring the broad scope of family medicine, including pain management, chronic kidney disease, menopause, bipolar disorder, rheumatology, and medical ethics. TAFP hosted the 23rd annual Texas Conference of Family Medicine Residents and Students on Saturday, which combined lectures tailored to future family physicians with an interactive resident-led residency and procedures fair. Morning speakers addressed the business of medicine, legislative challenges, and the many ways to customize your family medicine career to your interests. In the “business of medicine” lecture, TAFP past president Doug Curran, M.D., a rural family physician from Athens, Texas, gave attendees practical advice about staying involved in the financial side of running a practice, what items to include in a practice contract, and about continuing membership in professional organizations like TAFP to ensure they have a larger advocate in the health delivery system.
He ended with sage advice from a physician who has been in practice for decades. “Don’t get so involved in all of the dollars and numbers just to keep your practice going that you lose focus. It’s about the patients you care for, it’s about your community, it’s about serving other people. When you do that, the rest of it happens. You’ll make more money than you ever dreamed of making and you’ll have unbelievable job satisfaction. You’re becoming a member of the greatest profession in the world and the best segment of that profession. Welcome and enjoy.” That afternoon, residency programs from around Texas set up booths to promote their programs and show medical students the full scope of family medicine through hands-on procedure demonstrations. Students practiced simulations of joint injections, ultrasounds, and circumcisions, connected with their peers from other schools, and networked with residents. During TAFP commission, committee, section, and task force meetings on Friday and Saturday, TAFP members discussed top-
KATE ALFANO
ics that touch every aspect of family physicians’ practices, and developed policy that will guide the Academy through the year. At the Commission on Legislative and Public Affairs meeting Friday night, TAFP CEO Tom Banning discussed the past Texas legislative session and actions the Academy is taking in the interim and election cycle to positively position the specialty. He introduced Charles Bell, M.D., an internal medicine physician and former deputy executive commissioner for health services at the Texas Health and Human Services Commission, who updated the Commission on his work to develop policy recommendations to be presented to elected officials and crafted into potential legislation in the upcoming 83rd Texas Legislature. The Commission on Academic Affairs discussed leadership and advocacy training for family medicine residents and medical students that would prepare them for further involvement in the Academy. And the Section on Special Constituencies discussed current challenges to special constituency communities, including low rates of underrepresented minorities applying to medical school. The TAFP Board of Directors meeting concluded the weekend when board members heard all of the reports and recommendations from TAFP’s business meetings, and
Clockwise from top left: Residents from Texas Tech University Health Sciences Center of the Permian Basin demonstrate joint injections for medical students at the residency and procedures fair Saturday evening. Emily Briggs, M.D., M.P.H, answers questions on her solo practice at the 2012 Texas Conference of Family Medicine Residents and Students. The residency and procedures fair reconnects Rodrigo Ceballos M.D., left, and Matthew Brimberry, M.D., right, who first met when Ceballos was chief resident at Austin’s family medicine residency program and Brimberry was a rotating medical student. Texas A&M Family Medicine Residency Program represents the program and university in Aggie maroon. Ikemefuna Okwuwa, M.D., a third-year resident at TTHSC-Permian Basin, and Kenneth Barning, M.D., a Baylor College of Medicine resident, take a break at the residency fair. John Peter Smith Family Medicine Residency Program faculty Lesca Hadley, M.D., center, teaches ultrasound.
reports from TAFP and AAFP officers and delegates. Among other business, the board voted unanimously to support the candidacy of Lewis E. Foxhall, M.D., for re-election to the Texas Medical Association Board of Trustees. Mark your calendars now to join TAFP for next year’s C. Frank Webber Lectureship at the Omni Austin Hotel at Southpark on March 1, 2013. Also plan to join TAFP for its largest symposium, Annual Session and Scientific Assembly, July 11-15, 2012, at the Hilton
Austin Hotel and Austin Convention Center in downtown Austin. In the fall, TAFP will host Primary Care Summit – Houston, Oct. 26-28, 2012, at the Westin Oaks, and Primary Care Summit – Dallas/Fort Worth, Nov. 2-4, 2012, at the Westin Galleria Dallas. Stay connected to TAFP year-round through our social media outlets. Find us on Facebook at www.facebook.com/txafp, follow us on Twitter at www.twitter.com/ txfamilydocs, and read and comment on TAFP’s blog at www.tafp.org/blog. www.tafp.org
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12/21/09 2:52:24 PM
Member news
TAFP members appointed to Texas Institute for Health Care Quality and Efficiency texas governor rick perry has appointed 13 members to the board of directors of the Texas Institute for Health Care Quality and Efficiency, including three TAFP members. They are Kelsey-Seybold medical director Patrick Carter, M.D., M.B.A., F.A.A.F.P., New Braunfels family physician Beverly B. Nuckols, M.D., F.A.A.F.P., and St. Luke’s chief medical information officer John C. Joe, M.D., M.P.H., F.A.A.F.P. Pediatrician Ben Raimer, M.D., of Galveston, will chair the board. The 82nd Legislature created the Texas Institute for Health Care Quality and Efficiency as part of Senate Bill 7. The institute is charged with improving health care quality, accountability, education, and cost to the state by encouraging health care provider collaboration, effective health care delivery models, and coordination of health care services. Carter is medical director of care coordination and quality improvement at KelseySeybold Clinic in Houston. He is a member of AAFP, TAFP, the Harris County Medical Society, and the Harris County Academy of Family Physicians. He served in the U.S. Army. Carter received a bachelor’s degree from the University of Illinois, a medical degree from Rush Medical College, and a Master of Business Administration from the Stanford University Graduate School of Business. He is appointed for a term to expire Jan. 31, 2015. Nuckols is a board-certified family physician in private practice. She is a member of the Texas Medical Association, AAFP, TAFP, and the Comal County Medical Association. She serves on the board of directors for Texas Alliance for Life, New Braunfels Options for
Women, and is chair of the family medicine section of the Christian Medical and Dental Association. She has served as a member of the National Advisory Committee on Violence Against Women and the Texas Association Against Sexual Assault, and as a board member of the Comal County Women’s Shelter and New Braunfels Hospice. She received a bachelor’s degree from the University of Texas at Tyler, and received a medical degree from and completed a family medicine residency at the University of Texas Health Science Center at San Antonio. She received a master’s in bioethics in 2007 from Trinity International University in Deerfield, Ill. She is appointed for a term to expire Jan. 31, 2013. Joe is a physician and chief medical information officer at St. Luke’s Episcopal Health System in Houston. He is a past president of the Harris County AFP, and a member of AAFP, TAFP, the American Medical Informatics Association, the Federal Health Architecture Leadership Council, the Health Information and Management Systems Society, the Healthcare Information Technology Standards Panel, and the Society of NASA Flight Surgeons. He is also a volunteer physician for the Houston Healthcare for the Homeless clinic, and a member of the Harris County Medical Society’s Health Information Technology Committee. Joe was a National Merit Scholar at Rice University, and received a medical degree from Texas A&M University Health Science Center and a Master of Public Health from the University of Texas Health Science Center at Houston. He is appointed for a term to expire Jan. 31, 2013.
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TAFP Foundation funds family medicine research, awards scholarships the tafp foundation raises and distributes funds for medical student scholarships for students planning to pursue a career in family medicine, for family medicine office-based research, for family medicine student interest group activities at medical schools in Texas, and for family medicine resident activities.
The Foundation met during Interim Session and approved funding for two new practicebased, primary care research studies. The next round of applications is due June 1. For more information and to apply, go to the Foundation section of www.tafp.org. Support for TAFP Foundation research is made possible by the Family Medicine Research Champions. The first funded study is “Practical Opportunities for Healthy Behaviors” by Robert Ferrer, M.D., of the University of Texas Health Science Center at San Antonio Department of Family and Community Medicine. Ferrer et al. “seek to evaluate the social and environmental contexts that shape primary care patients’ health behaviors” and will “test the validity of a measure of practical opportunities for diet and physical activity that primary care practices can use to assess a patients’ potential success in altering those behaviors,” particularly those receiving care through the Residency Research Network of Texas. The second is “Comparative Analysis of the FRAX and the Male Osteoporosis Risk Estimation Score” by Alvah R. Cass, M.D., S.M., of the University of Texas Medical Branch at Galveston Department of Family Medicine. The authors seek “to compare the effectiveness of the Male Osteoporosis Risk Estimation Score (MORES) and FRAX to identify men at risk of osteoporosis, who would benefit most from a diagnostic DXA scan.” In addition, four TAFP-member medical students from the University of Texas Southwestern Medical Center in Dallas were awarded educational scholarships. Allison Peddle, a third-year student, and Kimberly Aparicio, a fourth-year student, will receive the William F. Ross, M.D. Scholarship. The TAFP Foundation scholarship’s namesake practiced many years in the San Benito, Texas, before becoming the first family practice chair at UT Southwestern. Francis Goldschmid, a fourth-year student, will receive the TAFP Foundation’s Minnie Lee Lancaster, M.D. and Edgar Lancaster, M.D. Scholarship, named for the longtime physicians who opened the first clinic in Grapevine, Texas, and help build the Grapevine Memorial Hospital and Clinic. Jennifer Chong, a fourth-year student, will receive the R. Michael Ragsdale, M.D. Scholarship. www.tafp.org
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topic: recovery audit contractors
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The age of audits and remediation By Kate Alfano
I
t’s a fact of medical practice that despite the best intentions, a physician who does not know how to correctly code for his or her services—or employ someone who does—will not stay in business for long. To be paid, physicians must reduce the complex art of medicine, their covenant with their patient, into a diagnosis, a procedure, a visit, a number. It is also generally understood that claims for evaluation and management services, the most common code set billed by family physicians, have high error rates because of their subjectivity. Of the more than 1 billion claims submitted in 2010 by more than 1 million Medicare providers, 43 million were E/M claims for new or established patients. And as Medicare consumes an increasing amount of federal spending—13 percent in 2010, or $452 billion—it’s no surprise that lawmakers, economists, and policy wonks would look to billing and coding for ways to reduce fraud, waste, and incorrect payments. Enter the recovery audit contractors, bounty hunters tasked with identifying “improper payments” submitted by any entity that bills Medicare Parts A and B, collecting overpayments, settling underpayments, and implementing actions to prevent future errors. Overpayments occur when a physician bills for an incorrect payment amount, perhaps through an outdated fee schedule; incorrectly codes; bills for non-covered services; or bills for duplicate services. AAFP says the RACs are homing in on consultations, E/M services provided on the same date as a procedure, E/M services provided during global periods, and relationships between physicians certifying durable medical equipment and suppliers of the equipment. The most common underpayment occurs when a physician submits a claim for a simple procedure when the medical record reveals that a more complicated procedure was performed, says Bradley Reiner, owner of Reiner Consulting and Associates and practice management consultant for TAFP.
The national RAC program as it stands is built on the foundation of a three-year demonstration that used contractors in six states—California, Florida, New York, Massachusetts, South Carolina, and Arizona—to detect and correct improper payments and to determine whether the use of third-party entities would be a cost-effective means of ensuring correct payments. From 2005 through 2008, they collected nearly $1 billion in overpayments and repaid $37.8 million in underpayments. The RACs referred only two cases of potential fraud to CMS, though they did not receive payments for those referrals. CMS awarded contracts to four private entities in 2008 to become the permanent recovery audit contractors. Atlantabased Connolly Healthcare won the contract for the largest region, Region C, which encompasses 15 states, including Texas, and two territories. The recovery auditors are paid a contingency fee for what they find based on their original bid to CMS, hence their notoriety among critics. Connolly’s is the lowest of the four regions at 9 percent; the highest, Region B, is 12.5 percent. An exception is the recovery of overpayments for durable medical equipment claims, which garners a fee of 14 percent for Connolly and 17.5 percent for Region B. CMS requires RACs to return the contingency fee if their claim determination is overturned at any point in the appeal process. So far, from October 2009 through December 2011, the RAC program has identified $1.45 billion in improper payments nationwide. Of this, $1.27 billion were overpayments collected and $183.7 million were underpayments corrected. Under the RAC demonstration program, approximately 96 percent of identified improper payments were overpayments. In the permanent program, 88 percent have been overpayments. CMS posts the most frequent types of issues undergoing review each quarter, and Connolly is required to maintain a list of all CMS-approved audit issues on their website, www. connolly.com. The top issue for Region C in the last quarter of 2011 was the medical necessity of neurological disorder in the inpatient hospital setting, ensuring medical documentation supported all billed services.
HIGHLIGHTS Recovery audit contractors are third parties hired by the Centers for Medicare and Medicaid Services to ensure that physicians are being paid correctly for Medicare Part A and B services. Connolly Healthcare is the RAC for Texas.
Improper payments could mean overpayments collected from physicians or underpayments reconciled. From October 2009 to December 2011, the RACs identified $1.45 billion in improper payments nationwide, $1.27 billion in overpayments and $183.7 million in underpayments.
After receiving the demand letter (in an automated review) or a reviewresults letter (in a complex review), the physician can initiate a discussion period, rebuttal, or an appeal, or he or she can pay the amount.
To minimize the risk of an audit, AAFP recommends employing a practice code of conduct; requiring annual compliance training that includes HIPAA, OSHA, state regulations, and billing and coding compliance; mandating that all staff sign and date medical record entries; and establishing procedures for billing and coding staff to question physicians about appropriate coding or missing documentation when necessary.
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The RACs are required to employ a fulltime physician medical director to oversee the medical record review process; assist, upon request, nurses and therapists with medical necessity reviews and certified medical coders with coding reviews; manage quality assurance; and maintain relationships with provider associations. Representatives from Connolly declined to be interviewed for this article. Audit staff conduct two types of reviews: automated and complex. Automated reviews analyze claims data in situations where there is certainty that the claim contains an overpayment. Complex reviews use human reviewers to look through medical records when there is a high degree of probability but not certainty that an overpayment exists. All reviews are conducted on a postpayment basis limited to three years after the claim was initially paid. The number of records the RAC can request is based on the size of the practice: ranging from 10 medical records per 45 days for a solo practice to up to 50 medical records per 45 days per physician in a large group practice. For audits that require medical documentation, Connolly accepts electronic transmissions through a secure transfer system, via CD or DVD, or by mailed paper copies. With some exceptions, the audit contractor must complete the complex review within 60 days of receiving the medical record Cindy documentation. The results are communicated to the practice by letter with details on which coverage, coding, or payment policy or article was violated if an improper payment was identified for each claim reviewed, or if no improper payment was identified. Cindy Hughes, former coding and compliance specialist for the American Academy of Family Physicians, says that most RAC au-
dits of physicians do not involve a request for medical records. “Rather, the audit contractor reviews claims data and notes an aberrancy— such as too many units billed for injectable drugs—and generates a demand for a refund of payments related to the number of units above a standard or medically likely dose.” Starting Jan. 3, the issuance of demand letters became the responsibility of the Medicare contractor that paid the claims, not the RAC. The RAC submits claim adjustments to the physician’s Medicare contractor—which in Texas is Trailblazer Health Enterprises. Then the MAC performs the adjustment based on the RAC review, issues an automated demand letter to the physician, and follows the process to recover any overpayment from the physician. The MAC is responsible for answering any administrative concerns such as the time frame of payment recovery or the appeals process. Specific audit questions, however, such as the rationale for identifying the potential improper payment, should be directed to the RAC. If the physician receives the demand letter, in an automated review, or a review-results letter, in a complex review, and disagrees and wishes to challenge the results, he or she can initiate a discussion period or an appeal. The discussion period offers the opportunity for the physician or practice to provide additional information to the RAC to indicate why overpayment Hughes should not be collected, and it offers the RAC the opportunity to explain the rationale for the overpayment decision. The practice must initiate a discussion period with the RAC within 40 days of receipt. After reviewing the additional documentation, the RAC can reverse the decision. The discussion period is not an appeal, nor does it remove the right of the physician
“Most RAC audits of physicians do not involve a request for medical records. Rather, the audit contractor reviews claims data and notes an aberrancy—such as too many units billed for injectable drugs—and generates a demand for a refund of payments related to the number of units above a standard or medically likely dose.”
to ask for an appeal. It also does not pause the 30-day time period in which the practice may ask for a redetermination, the first level of appeal. The redetermination and appeal are filed with the MAC, and the practice must file the full appeal request within 120 days of receipt of the letter. If the practice agrees with the RAC review, the physician or physicians may pay by check, allow recoupment from future payments, or request or apply for an extended payment plan. They may also initiate a rebuttal process with the MAC by providing a statement and accompanying evidence indicating why the overpayment action will cause a financial hardship and should not be collected. The rebuttal is not used to review medical documentation or dispute the review, and it must be initiated within 15 days of receipt of the letter. To minimize the risk of an audit, Hughes recommends that physicians implement a practice code of conduct; require annual compliance training including HIPAA, OSHA, state regulations, and billing and coding compliance; employ a documentation system that requires all staff to sign and date medical record entries; and establish procedures for billing and coding staff to question physicians about appropriate coding or missing documentation when necessary. She advises physicians or a designated compliance officer to make sure documentation is clear and complete for all services, learn the appeal process, track denied claims and correct previous errors, and determine what corrective actions need to be taken to ensure compliance with Medicare’s requirements to avoid submitting inaccurate claims in the future. Practice managers and staff must be trained to recognize and promptly respond to RAC audit letters, medical records requests, or requests from other program integrity contractors. A staff person who is responsible for reviewing denied claims and the reasons for denial should determine the proper course of action, whether refund, rebuttal, or appeal, and should continually monitor current RAC issues posted on the RAC website and the educational and payment policy information from local payers. Reiner agrees with Hughes, recommending that physicians stay up-to-date on what types of improper payments have been made in their RAC region. Physicians should regularly self-audit or employ a third-party auditor to examine patterns of denied claims, and should ensure physicians and their staffs are trained on and fully understand the 1995 or 1997 Documentation Guidelines, which are available on CMS’ website at www.cms.gov.
10 tips for preventing common evaluation and management coding errors By Bradley Reiner
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
The chief complaint, or CC, must be stated clearly. It identifies the medical necessity and sets the tone for the visit. A statement such as “follow up” or “comes in today” does not constitute a chief complaint. You must define why the patient is coming in to the office. Chief complaints must be documented for all levels of evaluation and management services.
The nature of the presenting problem must be clear and stated fully in the history of the present illness, or HPI. The higher-level codes require that four or more elements be documented or you must provide a description or status of three or more chronic conditions based on the 1997 Documentation Guidelines for Evaluation and Management Services.
A complete past/family/social history, or PFSH, is necessary for consults and new patient visits. This means that all three areas have to be documented for higher level E/M codes.
The review of systems, or ROS, must be appropriate for the clinical circumstances. The review must be related to the nature of the presenting problem and chief complaint. Record the positives and pertinent negatives. The phrase “all systems negative” is frowned upon by the Medicare contractor. It is recommended that each system be listed separately.
Always examine the system or systems related to the presenting problem. Use “normal” or “negative” to describe asymptomatic organ systems. “Abnormal” without elaboration is insufficient.
Code the physical exam considering the clinical circumstances of the encounter—don’t code based on unnecessary information added for the purposes of meeting the requirements of the higher-level codes.
Document all diagnostic tests ordered, reviewed, and independently interpreted or viewed as part of the work of the encounter.
Medical decision-making involves the number of diagnoses and management options as well as tests reviewed and ordered, and the risk of complications. Don’t assume this can be inferred. Clarify this in the assessment and plan.
It is unnecessary to count old diagnoses unless you can clearly demonstrate that their presence increased the work of the current encounter, or led to the complexity of the encounter.
Beware of software for electronic medical records that count and overestimate an established code based on the number of areas listed. Medical decision-making ultimately drives code choice. An EMR may suggest a high-level code because you documented all elements in the history and exam, but if the presenting problem was for an issue as minor as a hangnail, it would be inappropriate.
www.tafp.org
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Distribution of Medicare Part B Evaluation and Management Codes by Family Physicians, 2010
the most common codes billed by family physicians, are more subjective than any others and therefore open to scrutiny. The graph displays the sheer number of E/M codes billed to Medicare in 2010.
Percentages do not equal 100 due to rounding.
New patient 99201
20,045 (1%)
99202
249,223 (16%)
99203
709,541 (45%)
99204
476,260 (30%)
99205
108,041 (7%) 0
evaluation and management codes,
200,000
400,000
number of services 600,000
800,000
established patient 99211
1,529,711 (4%)
99212
1,765,760 (4%)
99213
19,802,800 (48%)
99214
16,533,719 (40%)
1,464,165 (4%)
99215 0
5M
10M
number of services 15M
20M
As Cindy Hughes, AAFP’s former coding and compliance specialist says, “an office visit for a middle-aged, obese female with multiple complaints and chronic conditions is scrutinized first on documentation of history, exam, and medical decision-making based on the payer’s interpretation of E/M coding guidelines; then someone other than the physician who was face-to-face with the patient may conclude that the documentation includes services that weren’t medically necessary for the complaints and conditions, and if any other services are provided at the time of the office visit, whether or not separate payment will be made for those.” That may be one reason why it may appear that physicians make more coding errors on E/M services than other codes. AAFP sent a formal request to Medicare asking that the claims review for E/M codes not include the level of service reported due to the complexity of interpreting physician documentation to support the codes reported. CMS responded that the review of duplicate claims of E/M services was available during the demonstration and will continue to be available for review, but that the review of the level of the visit of some E/M services was not included in the RAC demonstration. CMS pledged to “work closely the physician community prior to any reviews being completed regarding the level of the visit” and to “provide notice to the physician community before the RACs are allowed to begin reviews of evaluation and management services and the level of the visit.”
Online resource Go to the Compliance section of the AAFP Coding Resources page for a Code of Conduct and the OIG Compliance Plan for Small Practices: http://www.aafp.org/online/en/home/ practicemgt/codingresources.html#Parsys0003.15.
SOURCE: Centers for Medicare and Medicaid Services
Whether discovered through a RAC audit or any other reason, Hughes advises physicians to investigate any pattern of errors for cause and respond to it formally with education on why the errors occurred, compliance reviews to be sure that errors are reduced, and adjustments to practice processes as needed to prevent future errors. “Should a RAC audit show serious errors from a practice, there is the possibility that the RAC will involve a Medicare or Medicaid program integrity contractor or the Office of the Inspector General to further audit the practice,” she says. “When this occurs, it is important to show the practice’s efforts at being educated on correct coding and billing and correction efforts in response to problems found.” Some family medicine residency programs are adjusting their training to include documentation topics, recognizing the importance of the residents understanding how to correctly code and bill and avoid pitfalls in 24
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preparation for entering practice. Todd Thames, M.D., program director of the Christus Santa Rosa Family Medicine Residency Program in San Antonio, says that his program holds a regular family medicine practice management lecture series on coding and billing. In addition, all of their residents do their own coding in the clinic from day one, under faculty supervision. More important is a quarterly lecture given by an outside billing consultant on coding guidelines, reimbursement alerts, and any other changes, who afterward conducts individual meetings with each resident and faculty member to go over the results of a coding audit of his or her claims that has been generated by a third-party auditor. “It’s vital” to the training experience, Thames says. He advises other Texas family medicine residencies to integrate coding and billing into the resident experience and build in a concurrent audit system that includes the
residents so they get regular feedback on how their coding and billing compares to internal benchmarks and national benchmarks. “We tell the residents all the time, ‘we can teach you medicine until the cows come home, but if you don’t know how to keep your doors open, you can’t do the community any good.’” As the RACs continue to produce significant results in identifying improper payments in Medicare, Reiner says there is no doubt that everyone will undergo a RAC audit sooner or later. “In almost every practice, a RAC can find some billing, coding, or documentation issue during any given audit. It is easy to make mistakes even if you have all of the right processes in place. The rules are too complex and differ from payer to payer.” “Having a compliance plan in place and documentation training can help decrease the risk of an audit or overpayments. It is not a matter of if, but when, in regards to auditing medical practices.”
TMB rules you may not know but should . . . part 1 By TMLT Risk Management Department
Texas Medical Board rules, which regulate the activities of Texas physicians, consist of 156,165 words on 244 single-spaced pages. While most physicians are familiar with the basic concepts of these regulations, there are several specific rules that seem to give physicians the most trouble. This article will discuss these more challenging TMB rules in an effort to enhance knowledge of the TMB, reduce exposure to disciplinary actions by the board, and assist in the physician’s defense should a TMB action occur. Part 1 will address physician advertising, actions to take when leaving a medical practice, documentation of patient encounters, and documentation of prescriptions.
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1. Physician advertising The TMB has established rules for use of the term “board certified” in advertising. “A physician is authorized to use the term ‘board certified’ in any advertising for his or her practice only if the specialty board that conferred the certification and the certifying organization is a member board of the American Board of Medical Specialties, or the Bureau of Osteopathic Specialists, or is the American Board of Oral and Maxillofacial Surgery.” Physicians may advertise certification by other types of organizations only if the organization meets certain requirements, as specified in TMB advertising rules.1 These rules also expressly prohibit use of the terms “board eligible” or “board qualified” in physician advertising. The board has determined that these terms are misleading and cause confusion about a physician’s board certification status.1 TMB rules also expressly prohibit advertising that is “in any way false, deceptive, or misleading.” Any statement made about the physician’s professional experience, competence, or quality should only be made if it can be supported by facts.1 For example, if a physician were to say in an ad that he was “among the most highly qualified neurosurgeons in the southwest,” then he must have objective data to support the comparison of his qualifications to the other neurosurgeons in the southwest. Because it is unlikely that the neurosurgeon has data to support this statement, its use should be avoided.1 Do not advertise the sale of products—any products—according to TMB rule 164.6(c). “Advertising or promotion of goods or products from which the physician receives direct remuneration or incentives is prohibited.” This prohibition appears to encompass nutritional supplements, cosmetics, eyeglasses, hearing aids, and other products commonly sold at physicians’ offices. It is unclear if the rule is intended to include products that must be injected or surgically installed, such as Botox or implantable medical devices. Further, we interpret the rule to include instances in which the physician’s website advertises a product that is not for sale by the physician, but his website links to a thirdparty website for purchase of the product. If use of the link by the patient allows the physician to be paid a fee by the third-party seller, then the physician is receiving direct remuneration for sale of the product.1 Physicians planning to advertise, whether through a website, Yellow Pages ad, or televi-
sion commercial, should become familiar with the TMB’s rules for physician advertising. Editor’s note: On May 5, 2011, as this article was being published, the TMB changed the language of the advertising rule. The rule now states: “(c) Advertising/Promotion of Goods or Products. Advertising or promotion of goods or products that a licensee sells outside the normal course of business from which the physician receives direct remuneration or incentives is prohibited.” This appears to be a substantial reduction of the previous prohibition regarding the advertising of products for sale. We do not yet have clarification of exactly what this is intended to mean. Additionally, we have been in contact with the TMB regarding the new rule and we believe that it contains an error that the TMB will remedy in the upcoming months. The error pertains to the new subsection (d) of rule 164.6 that states: “(d) This section applies only to licensees who bill for services provided via the Internet.” This new subsection could be interpreted to mean that the newly modified advertising rule will apply only if you bill for services provided via the Internet. We have information from the TMB that they did not intend to limit the advertising prohibition in this way. We believe they will remedy this error. The outcome may be that all physicians will be limited to advertising products that they sell in the normal course of business, and no physician may advertise products that they sell outside the normal course of business.
2. Leaving a medical practice The board rules found in section 165 are lengthy and complex. Among other issues, this rule describes how physicians should notify patients that they are leaving their current practice site. The most interesting sentence in this rule is found in Section 165.5(e), which makes it a criminal violation to violate any part of this rule. Hard to believe, but true. This rule specifies what actions must be taken when a physician leaves his or her current practice. The departing physician must do three things: send letters to all patients seen in the last two years notifying them of the change in the practice, post a prominent notice in the office for 30 days before the change, and publish a notice in the largest local newspaper. The departing physician’s failure to comply with this rule is often brought to the attention of the board by a
patient who is contacting the board because the physician’s former practice will not tell the patient where to find the physician. Any time physicians begin contemplating a move or retirement, it may be helpful to begin gathering the names and addresses of active patients as they are seen in the office. Interestingly, there are only two requirements for the remaining members of the group. They must stay out of the way of the departing physician and give the departing physician access to the information he or she needs to provide proper notice to patients.2
3. Documentation Board rule 165 also requires proper charting of each “patient encounter.” Proper charting includes a SOAP note or its equivalent, the date, and the legible identity of the physician. It is important to note that the rule does not just require the identity of the physician, but specifically requires the “legible identity.” What constitutes a patient encounter? If a physician takes a phone call from the patient of his or her call partner, is that a patient encounter that must be charted? How is the encounter charted when the physician does not have access to the patient’s chart? In general, it is a patient encounter if the physician received medical information from the person and gave medical advice in return. Even if the advice was simply to go to the emergency department, that is a patient encounter. Brief phone consultations are also considered patient encounters that need to be charted.2 A good solution for charting these encounters—even if the physician was covering call for another physician—is to have a designated voicemail box that the physician can call to leave a dictated message. The dictated message can later be turned into a chart note and faxed or e-mailed to the patient’s physician. This simple system satisfies the charting rule while promoting continuity of care. Of special note is the potential misuse of electronic medical records or of any other type of charting system that facilitates the use of “default” text in a patient’s chart. “Default text” is any pre-inserted text that will remain in the chart unless changed by the user. Some EMRs use language describing “normal findings” in the review of systems. If this default language is not altered, it will remain in the chart indicating that the physician completed a review of systems. If this review of systems was not done or if the find
ings were not normal and the EMR defaults to “normal,” the record is inaccurate. During the investigation of a medical liability claim or a board complaint, it is often apparent that these default statements are not true regarding the patient in question, implying that the examination of the patient was incomplete or the charting was sloppy.
The TMB also prohibits the prescription of controlled substances for more than 72 hours to oneself, family members, or others in which there is a close personal relationship. This rule covers prescriptions for medications such as zolpidem, amphetamine and dextroamphetamine, diazepam, alprazolam, and hydrocodone.4
4. Documenting prescriptions
Conclusion
Board rule 165.1 requires that the chart should include documentation of prescriptions (including samples) specifying the amount, frequency, number of refills, and dosage. While it may seem obvious to include these details in the chart, it is often the case that the total amount of medication prescribed cannot be determined from the medical record. In most cases when we are defending a physician, we must obtain the pharmacy records to determine dosage, frequency, and number of refills for a medication. The lack of information in the chart becomes a problem most often when there are allegations of failure to adequately control or monitor medications. When members of the TMB review the chart and cannot determine the number of pills prescribed, they conclude that the physician cannot determine this either. Along with properly charting that drug samples were given to the patient, physicians should maintain records of samples obtained from drug companies for two years.2 Best practices in charting prescriptions require the physician to keep a medication list for each patient that is updated at each visit. This list should include all medications the patient reports taking. If this information is not easily accessible, adverse drug reactions can occur. In regard to Schedule II drug prescriptions, avoid post-dating prescriptions. A post-dated prescription for any controlled substance is illegal. The proper way to write a controlled substance prescription to be filled at a later date is to write today’s date and then also write the future date along with the words “earliest fill date.” The new official prescription forms from the Department of Public Safety prompt the physician to write both dates. It is legal to write a 90-day prescription for a Schedule II drug on a single prescription sheet if the physician believes that 90-day prescribing is appropriate. However, pre-signing a Schedule II prescription pad is illegal. The signature must be written at the same time or after the remainder of the prescription is written.3
With its mission to protect the public and ensure a sufficiently trained physician workforce, the TMB is poised to enforce all rules for which it has responsibility. The practice of medicine is highly regulated and each licensed physician needs to be aware of current TMB guidelines and rules. Part 2 of this article will address officebased anesthesia rules, standing delegation rules, and physician website rules. It will be published in the next edition of Texas Family Physician, Vol. 63 No. 3. 1. Texas Medical Board. Board Rules. Texas Administrative Code, Title 22, Part 9, Chapter 164, section 164.1-164.6. Available at http://www.tmb.state.tx.us/rules/rules/ bdrules_toc.php. Accessed March 11, 2011. 2. Texas Medical Board. Board Rules. Texas Administrative Code, Title 22, Part 9, Chapter 165, section 165.1-165.6 Available at http://www.tmb.state.tx.us/rules/rules/ bdrules_toc.php. Accessed March 11, 2011. 3. Health and Safety Code. Section 481.075 (1) (2). Available at http://www.statutes. legis.state.tx.us/docs/hs/htm/hs.481.htm. Accessed March 17, 2011. 4. Texas Medical Board. Board Rules. Texas Administrative Code, Title 22, Part 9, Chapter 190, section 190.8(1)(M)(ii). Available at http://www.tmb.state.tx.us/rules/ rules/bdrules_toc.php. Accessed March 11, 2011. The information and opinions in this article should not be used or referred to as primary legal sources nor construed as establishing medical standards of care for the purposes of litigation, including expert testimony. The standard of care is dependent upon the particular facts and circumstances of each individual case and no generalization can be made that would apply to all cases. The information presented should be used as a resource, selected and adapted with the advice of your attorney. It is distributed with the understanding that neither Texas Medical Liability Trust nor Texas Medical Insurance Company is engaged in rendering legal services. © Copyright 2011 TMLT. www.tafp.org
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risk management
Closed claim study Failure to restart anticoagulants By TMLT Risk Management Department
This closed claim study is based on an actual malpractice claim from Texas Medical Liability Trust. This case illustrates how action or inaction on the part of physicians led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physicians’ defensibility. The ultimate goal in presenting this case is to help physicians practice safe medicine. An attempt has been made to make the material more difficult to identify. If you recognize your own claim, please be assured it is presented solely to emphasize the issues of the case.
Presentation—A 66-year-old man came to an internal medicine physician with a complaint of shuffling gait. He had a complex medical history, including a history of stroke. The internal medicine physician referred the patient to a neurologist. Before the patient’s scheduled appointment with the neurologist, the patient was admitted to the hospital with increasing weakness of the lower extremities. A cardiac workup was completed and cardiac insufficiency was diagnosed. Physician action—Two weeks after the initial referral, the neurologist saw the patient. A neurologic examination was documented as hyperreflexia of the lower extremities (later this was reported to be a transcription error and should have read hyporeflexia). Also noted on the exam was decreased sensation in both feet. Differential diagnosis at this time included chronic polyneuropathy with a suspicion for chronic inflammatory demyelinating polyneuropathy and normal pressure hydrocephalus (NPH). The neurologist ordered lab work, nerve conduction studies, and a lumbar puncture. The neurologist noted that he would call the patient’s cardiologist to discuss stopping the patient’s warfarin before the lumbar puncture. There is no documentation of a phone call between the neurologist and the cardiologist. Before the lumbar puncture could be done, the patient developed a viral illness and was admitted to the hospital under the care of a hospitalist. Following this hospital stay, the patient returned to the neurologist. The neurologist dictated a letter to the patient’s internal medicine physician and the patient’s cardiologist that nerve conduction studies showed decreased reflexes and that a lumbar puncture had been scheduled. 28
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During his deposition, the neurologist stated that he instructed the patient and family to stop the warfarin; however, these instructions were not documented in the medical record. The lumbar puncture under fluoroscopy was completed as an outpatient procedure at a local hospital. The patient did not report any problems to the neurologist during a post-procedure phone call. There was no mention in the medical record about the patient’s warfarin. The hospital records did not include any discharge instructions given by the neurologist or the hospital staff. Seven days after the lumbar puncture, the patient returned to the neurologist. Analysis of the spinal fluid revealed protein 40 mg/ dL; WBC 18 (100 percent lymphocytes); and glucose 51 mg/dL. The neurologist confirmed the diagnosis of Guillain-Barre syndrome with cervical canal stenosis. The neurologist recommended treatment with IVIG. There was no documented review of the patient’s current medications or a documentation of a discussion about restarting the patient’s warfarin. Following this visit to the neurologist, the internal medicine physician saw the patient. Documentation from this visit did not include any discussion of the patient’s medications. Before the patient could be started on the IVIG treatment, he suffered a stroke and died. Allegations—Lawsuits were filed against the internal medicine physician and the neurologist. The allegations were based on the patient’s discontinuation of warfarin and the failure of the physicians to address restarting the medication. The plaintiffs claimed this was the cause of the patient’s CVA and death. Legal implications—During the investigation of this claim, there was considerable disagreement about the discontinuation of the patient’s warfarin. The neurologist stated that he instructed the patient to hold the warfarin for only a few days before the lumbar puncture. The internal medicine physician, home health records, and the family all agreed that the warfarin was stopped approximately two weeks before the procedure, as instructed during the patient’s first visit. The neurologist’s medical records did not make any reference to the patient’s warfarin.
Risk management considerations—Documenting the review of current medications at each office visit is good practice. This gives the physician the opportunity to identify compliance or noncompliance with medication plans. Both the neurologist and the internal medicine physician saw the patient after the procedure and had an opportunity to determine that the warfarin had not been restarted. Developing a process to document pre-procedure instructions given to patients and families is encouraged. It is helpful to provide the patient and family with written instructions to help minimize confusion and maximize compliance with special instructions. It is also helpful to document phone calls with the patient, the patient’s family, and other practitioners. This documentation provides valuable information to subsequent treaters and may play an important role in the defense of the case, if litigation occurs. Good communication between caregivers is a valuable tool for the management of patients on anticoagulants. When multiple physicians are involved in the care of a patient, it is helpful to determine and document who will be responsible for the management of the anticoagulation therapy. With outpatient procedures, it is important to communicate post-procedure instructions to be included in the patient’s discharge instructions. Complex medical problems, multiple medications, and a compliment of medical specialists may result in confusion for patients and
their families. This can lead to noncompliance with the medical management plan. In this closed claim, the discontinuation of warfarin to facilitate a lumbar puncture may have contributed to the patient’s subsequent CVA. Communication between providers and patients is essential to ensure compliance. Documentation in the medical record of special instructions and patient/family understanding of them is important in the defense of insured physicians. Disposition—This case was settled on behalf of the neurologist. The case against the internal medicine physician was dismissed.
The information and opinions in this article should not be used or referred to as primary legal sources nor construed as establishing medical standards of care for the purposes of litigation, including expert testimony. The standard of care is dependent upon the particular facts and circumstances of each individual case and no generalization can be made that would apply to all cases. The information presented should be used as a resource, selected and adapted with the advice of your attorney. It is distributed with the understanding that neither Texas Medical Liability Trust nor Texas Medical Insurance Company is engaged in rendering legal services. © Copyright 2012 TMLT.
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NUTRITION
New meal standards for schools help kids make the right nutritional choices By Teresa Wagner, M.S., R.D./L.D. Program Director, Dairy Max Incorporated on jan. 25, 2012, first lady Michelle Obama and Agriculture Secretary Tom Vilsack unveiled new standards for school meals that will result in healthier meals for kids across the nation. The new meal requirements will raise standards for the first time in more than 15 years and improve the health and nutrition of nearly 32 million kids that participate in school meal programs every school day. The healthier meal requirements are a key component of the Healthy, Hunger-Free Kids Act of 2010, which was championed by the first lady as part of her “Let’s Move!” campaign and signed into law by President Obama. The final standards make practical changes that ensure children have access to nutrient-rich food choices at school to help them be successful in developing healthy lifestyles they can carry into adulthood. Those standards include: • Ensuring students are offered both fruits and vegetables every day of the week; • Substantially increasing offerings of whole-grain-rich foods; • Offering only fat-free or low-fat milk varieties; • Limiting calories based on the age of children being served to ensure proper portion size; and • Increasing the focus on reducing the amounts of saturated fat, trans fats, and sodium. The U.S. Department of Agriculture built the new rule around recommendations from a panel of experts convened by the Institute of Medicine. The standards were also updated with key changes from the 2010 Dietary Guidelines for Americans and aimed to foster the kind of healthy changes at school that many parents are already trying to encourage at home, such as making sure that kids are offered both fruits and vegetables each day, 30
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more whole grains, and portion sizes that provide calorie counts designed to maintain a healthy weight. These standards fall nicely in line with the premise of the Fuel Up to Play 60 program. Fuel Up to Play 60 is an in-school nutrition
and physical activity program launched by National Dairy Council and National Football League, in collaboration with the USDA. The program encourages youth to consume nutrient-rich foods (low-fat and fat-free dairy foods, fruits, vegetables, and whole grains) and achieve at least 60 minutes of physical activity every day. Research shows that kids who are well-nourished and more physically active tend to have improved cognitive function, stronger academic achievement, increased concentration, and better test scores. The bottom line is that Fuel Up to Play 60 can help improve the health, achievement, and longterm well-being for students in schools. The dietary guidelines state three servings of dairy foods every day are an important part
of balanced diet contributing key nutrients needed for good health. Milk, cheese, and yogurt contribute those same important nutrients to the school meal program. In fact, milk, flavored or plain, is the number one food source of calcium, potassium, and vitamin D in children’s diets and continues to be required to be offered at both breakfast and lunch. The great news is that one-third of the flavored milk available is already fat-free and many processors have lowered the sugar content. Flavored milk in general contributes only 3 percent of the added sugars in children’s diets compared with almost 50 percent contributed by soda and fruit drinks. Dairy foods in general continue to play an important role in the school breakfast and lunch programs due to their nutritional and economic value. The dairy industry is continuing to innovate to find product improvements and solutions that will fit the needs of schools and communities across America, and is helping to improve the nutrition and physical activity opportunities at school through the Fuel Up to Play 60 program. Schools and youth can sign up for the program by visiting www.FuelUpToPlay60. com. On the website, students can take a pledge, get involved in challenges, learn from other students, track their physical activity and healthy eating behaviors, earn rewards, and explore ways to get healthy and be active. Adults can sign up to be program advisors or supporters. Schools can apply for competitive funding and find out who else in the school is involved in Fuel Up to Play 60. Funding is based on the quality of the application and sustainability of the specific request. Find out more from your local dairy council representative at wagnert@dairymax.org.
© 2012 National Dairy Council. Fuel Up is a service mark of the National Dairy Council.
Prescribe more than just medicine.
case manag ement
When he can’t find the medical equipment he needs, refer him for case management services, a Medicaid benefit for children birth through age 20 and high-risk pregnant women. Case managers help patients navigate the health system by providing access to medical, dental, behavioral health, educational, and social services related to their health conditions. To make a referral, call 1-877-THSTEPS or download a referral form at www.dshs.state.tx.us/caseman.
RESEARCH
Changes in complexity of ambulatory care from 2005 to 2008 across disciplines Support for TAFP Foundation Research is made possible by the Family Medicine Research Champions.
Gold level Richard Garrison, M.D. David A. Katerndahl, M.D. Jim and Karen White Bronze level Joane Baumer, M.D. Carol and Dale Moquist, M.D. Lloyd Van Winkle, M.D. George Zenner, M.D. Thank you to all who have donated to an endowment.
For information on donating or creating a new endowment or applying for research grants, contact Kathy McCarthy at kmccarthy@tafp.org.
By David A. Katerndahl, M.D., M.A.; Robert Wood, Dr. P.H., Carlos R. Jaén, M.D., Ph.D.
between 1996 and 2001, more primary care physicians perceived that the complexity of care they provided was increasing (from 32 percent of physicians in 1996-1997 to 36 percent physicians in 2000-2001) according to the Community Tracking Survey (Kemper et al., 1996; Metcalf et al., 1996). In addition, 26 percent of physicians believed that the complexity of care they were expected to provide was greater than it should be. Such increasing complexity could have several ramifications. First, as systems become more complex, the rate of errors rises (Bar-Yam, 1997). The risk of errors increases with incomplete knowledge, seeing multiple patients, use of multiple medications, and implementation of complex procedures (Croskerry et al., 2004). These conditions seem to describe primary care and may explain why errors were found to occur in 24 percent of family medicine office visits (Elder et al., 2004). This is consistent with error reduction strategies which advocate ways that reduce unnecessary complexity, such as standardizing approaches, bundling related tasks, and using pre-existing habits (Elgert, 2005). A second potential impact would be a decline in perceived autonomy and ultimately career satisfaction among primary care physicians (Katerndahl et al., 2009). In a recent physician survey, only 31 percent of physicians felt that their autonomy met or exceeded their expectations (Hadley et al., 1999) and perceptions of autonomy are generally poorer among primary care than specialty care physicians (Burdi and Baker, 1999). Similarly, between 1991 and 1996, the proportion of physicians who indicate that they are very satisfied with their careers dropped from 48 percent to 37 percent (Burdi and Baker, 1999) while a survey published in 1999 put that figure at 33 percent (Hadley et al., 1999). Although there is no evidence that these declines are due to an increase in perceived complexity, the trends are consistent with that explanation. Thirdly, in an attempt to cope with perceived complexity, one approach would be to lower the threshold at which patients are referred to specialists. In fact, one study found that the referral rate from primary care physicians more than doubled between 1978 and 1994 (Stafford et al., 1999). A final potential consequence of increased complexity of care is a reduction in the overall quality of care provided (St. Peter et al., 1999). This may explain why only 55 percent of adult patients received recommended care (McGlynn
et al., 2003). Poor quality of care was especially noted in time-intensive activities, such as history-taking, counseling, and patient education (McGlynn et al., 2003) as well as screening and preventive medicine (Asch et al., 2006). By the increasing perceived complexity, there are trends suggesting a decrease in the services provided by primary care physicians (Mechanic et al., 2001; Safran, 2003). Comparison studies suggest that the quality of care provided for specific medical conditions is “poorer” in primary care than in specialty settings. For example, family physicians more often recommend therapies which are less beneficial for acute myocardial infarction than do cardiologists (Ayanian et al., 1994). In addition, cardiologists are less likely to order tests but prescribe more medications for hypertension and ischemic heart disease (Greenwald et al., 1984). Cardiologists also perform more cardiac catheterizations in patients with heart failure (Philbin and Jenkins, 2000). Similar differences between family physicians and psychiatrists have been reported in patients with mental disorders. Studies suggest that, compared with psychiatrists, primary care physicians more often fail to detect mental disorders (Thompson et al., 2001; Rost et al., 1998; Simon et al., 1999), make more diagnostic errors (Ryan, 1994; Hoffman, 1982), and more often use inappropriate or inadequate dosages of psychotropic medications (Katon et al., 1995; Olfson and Klerman, 1993). Using a recently developed approach for estimating relative complexity of ambulatory care, Katerndahl et al. (2011) found that there was minimal difference in the unadjusted input and total encounter complexity of general/family practice and cardiology in 2000; psychiatry’s input was less complex. Cardiology encounters involved more input quantitatively, but the diversity of general/family practice input eliminated the difference. Cardiology also involved more complex output. However, when the duration of visit was factored in, the complexity of care provided per hour in general/family practice was 33 percent more relative to cardiology and five times more relative to psychiatry. The purpose of this study was to estimate changes in the complexity of patient encounters in three disciplines (family medicine, cardiology, and psychiatry) using data from two years of the National Ambulatory Medical Care Survey. www.tafp.org
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TABLE 1. Complexity across disciplines (weighted mean#)
General/Family Practice
Category
Complexity per visit
Complexity per hour*
Cardiology Complexity per visit
Psychiatry
Complexity per hour*
Complexity per visit
Complexity per hour*
2005
2008
2005
2008
2005
2008
2005
2008
2005
2008
2005
2008
Reasons for visit
0.74
0.74
2.34
2.32
0.57
0.57
1.85
1.86
0.57
0.55
1.11
1.02
Diagnoses
0.84
0.85
2.66
2.67
0.77
0.84
2.50
2.74
0.59
0.58
1.15
1.07
Examination/testing
0.66
0.65
2.09
2.04
0.60
0.63
1.95
2.06
0.10
0.11
0.19
0.20
Patient characteristics
1.96
1.97
6.21
6.18
1.86
1.86
6.05
6.07
1.93
1.93
3.75
3.57
Input
Output Medications
1.46
1.42
4.62
4.45
1.90
2.14
6.18
6.98
0.95
0.90
1.84
1.75
Procedures
0.05
0.06
0.16
0.19
0.03
0.02
0.10
0.07
0.01
0.02
0.02
0.04
Other therapies
0.52
0.47
1.65
1.47
0.67
0.52
2.18
1.70
0.92
0.72
1.79
1.40
Disposition
0.69
0.69
2.19
2.16
0.69
0.69
2.24
2.25
0.63
0.63
1.22
1.16
Total
2.72
2.64
8.61
8.28
3.29
3.36
10.70
10.96
2.50
2.26
4.85
4.18
Total encounter (SE)
49.90
48.47
158.0
152.0
46.19
50.65
150.2
165.3
22.84
20.34
44.3
37.6
(.004)
(.004)
(.013)
(.012)
(.002)
(.001)
(.005)
(.006)
(.004)
(.002)
(.007)
(.004)
* Adjusted for duration of visit # SE less than or equal to 0.0004
Methods In a prior study funded through the Texas Academy of Family Physicians Foundation (Katerndahl et al., 2010), we developed and evaluated a method for estimating relative complexity based upon the quantity, diversity, and variability of clinical encounters, derived from national databases. In this study, we used this method to analyze data from two years of the NAMCS databases (NCHS, 2005; NCHS, 2008) for family practice, cardiology, and psychiatry; the 2005 and 2008 databases were used because the data fields were quite similar for years 2005-2008. Computation of Complexity of Each Input/Output. The complexity of each input/output is defined as the mean input/output per clinical encounter weighted by its inter-encounter diversity and variability. Thus, the complexity of diagnoses seen in family practice would be the product of the mean number of diagnoses seen in family practice encounters (1.75 diagnoses using the 2000 NAMCS data), the inter-encounter diversity of diagnoses weighting, and the inter-encounter variability of diagnoses weighting. The diversity of an input/ output is defined as the proportion of the number of categories needed to include 95 percent of the input/ output reported out of the total possible categories. The 95-percent proportion was chosen to minimize the impact of a rare or miscoded input/output. The variability was defined as the coefficient of variation (COV) of the input/output, which is calculated as the standard 34
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deviation divided by the mean. The COV was chosen over other measures of variation because it is a unitfree measure (Armitage and Berry, 1987). To standardize the weightings and limit the impact of low diversity or variability on complexity, the weightings used are the Z-transformations of the diversity proportion and the COV, and range between 0.5 and 1.0. Computation of Total Complexity. Once the complexity of each component has been calculated, the total input and total output complexities are calculated by summing the component complexities (Bar-Yam, 1997). However, calculation of the total specialty complexity is not merely the sum of the input and output complexities. A fundamental principle of complex systems is that there is a logarithmic relationship between input and output, so that, as the information in the input increases linearly, the complexity of the system increases exponentially. Thus, for binary data, the total system complexity is determined by the following formula (Bar-Yam, 1997):
System Complexity
Output = X 2(Input Complexity) Complexity
In the complexity of family practice using the 2000 NAMCS data, the total input complexity is the sum of the complexities of reasons-for-visit (0.78), diagnoses (0.82), examination/testing (0.83), and patient characteristics (1.97). Using the formula presented above, we calculate the total specialty complexity as:
System Complexity
Output = X 2(Input Complexity) Complexity
45.46
=
2.15 X
2(4.40)
Finally, we can determine confidence intervals around estimates using bootstrap methods. If we are to assess the impact of the complexity of the encounter on the physician, we need to adjust the estimated complexity for the duration of visit. Temte et al. (2007) have suggested the encounter problem density (number of clinical problems addressed per hour) as a measure of complexity. Although simpler to measure, such assessments do not address the diversity and variability of patients and problems, which also contribute to the mental burden to the physician. For our purposes, the estimated complexity is divided by the duration of visit to obtain the complexity per minute. An hourly complexity density estimate (Temte et al., 2007) is derived by multiplying the complexity per minute by 60. The complexity density represents the complexity burden on the physician.
Results Table 1 presents the final results of this analysis. In all cases, family medicine and cardiology provided significantly more complex care than did psychiatry. From 2005 to 2008, the complexity of ambulatory care provided by family physicians and psychiatrists declined slightly due primarily to a decrease medication and non-medication therapies; overall, care in family medicine visits was more than twice as complex as in psychiatric visits. However, the complexity of ambulatory cardiology care rose with increases in both input and output complexity primarily due to increased complexity of diagnoses and medications. In addition, complexity density also declined for both family medicine and psychiatry due primarily to increases in the mean durations of visit for both disciplines from 18.95 to 19.13 minutes in family medicine and from 30.90 to 32.47 minutes in psychiatry. Cardiology, however, reported a slight decline in mean duration of visit from 18.45 to 18.39 minutes between 2005 and 2008 with a resulting increase in input and output complexity densities. While family medicine had the most overall complexity density in 2005 (158) compared with cardiology (150), by 2008, that of cardiology had surpassed family medicine (165 versus 152).
Discussion Changes in complexity of visits and complexity density for disciplines may have important implications. First, complex systems generate errors in proportion to the level of complexity of the system (Bar-Yam, 1997). Thus, we should anticipate that the risk of medical errors may be increasing for cardiology but declining in family medicine. Second, because perceived complexity
correlates with perceived clinical autonomy and career satisfaction (Katerndahl et al., 2009), these observed changes may represent good news for family medicine but a warning for cardiology. Finally, the continuing mismatch between complexity of care provided and levels of reimbursement must be addressed.
References Armitage P, Berry G: Statistical Methods In Medical Research (2nd ed). Boston: Blackwell Scientific Publications, 1987. Asch SM, Kerr EA, Keesey J, Adams JL, Setodji CM, Malik S, McGlynn EA: Who is at greatest risk for receiving poor quality of health care? N Engl J Med 2006; 354:1147-56. Ayanian JZ, Hauptman PJ, Guadagnoli E, Antman EM, Pashos CL, McNeil BJ: Knowledge and practices of generalist and specialist physicians regarding drug therapy for acute myocardial infarction. N Engl J Med 1994; 331:1136-42. Bar-Yam Y: Dynamics of Complex Systems. Reading, MA: Perseus Books, 1997. Burdi MD, Baker LC: Physicians’ perceptions of autonomy and satisfaction in California. Health Affairs 1999; 18:134-45. Croskerry P, Shapiro M, Campbell S, LeBlanc C, Sinclair D, Wren P, Marcoux M: Profiles in patient safety. Acad Emerg Med 2004; 11:289-99. Elder NC, Vander Meulen MB, Cassedy A: Identification of medical errors by family physicians during outpatient visits. Ann Fam Med 2004; 2:125-9. Elgert S: Reliability science. Fam Pract Mgmt 2005; October issue:59-63. Greenwald HP, Peterson ML, Garrison LP, Hart LG, Moscovice IS, Hall TL, Perrin EB: Interspecialty variation in office-based care. Med Care 1984; 22:14-29. Hadley J, Mitchell JM, Sulmasy DP, Bloche MG: Perceived financial incentives, HMO market penetration, and physicians’ practice styles and satisfaction. HSR 1999; 34:307-21. Hoffman RS: Diagnostic errors in the evaluation of behavioral disorders. JAMA 1982; 248:964-7. Katerndahl DA, Parchman M, Wood R: Perceived complexity of care, perceived autonomy, and career satisfaction among primary care physicians Journal of the American Board of Family Medicine 2009; 22:24-33. Katerndahl DA, Wood R, Jaén CR. A method for estimating relative complexity of ambulatory care. Annals of Family Medicine 2010; 8:341-347. Katerndahl DA, Wood R, Jaén CR. Family medicine outpatient encounters are more complex than those of cardiology and psychiatry. Journal of the American Board of Family Medicine 2011; 24:6-15. Katon W, Von Korff M, Lin E, Walker E, Simon GE, Bush T, Robinson P, Russo J: Collaborative management to achieve treatment guidelines. JAMA 1995; 273:1026-31. www.tafp.org
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Kemper P, Blumenthal D, Corrigan JM, et al.: Design of the Community Tracking Study. Inquiry 1996; 33:195-206. McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA: Quality of health care delivered to adults in the United States. N Engl J Med 2003; 348:2635-45. Mechanic D, McAlpine DD, Rosenthal M: Are patients’ office visits with physicians getting shorter? N Engl J Med 2001; 344:198-204. Metcalf CE, Kemper P, Kohn LT, Pickreign JD: Site definition and sample design for the Community Tracking Study. Washington, DC: Center for Studying Health System Change, 1996. National Center for Health Statistics. National Ambulatory Medical Care Survey. Hyattsville, MD: U.S. Department of Health and Human Services, 2005 and 2008. Olfson M, Klerman GL: Trends in the prescription of psychotropic medications. Med Care 1993; 31:559-64. Philbin EF, Jenkins PL: Differences between patients with heart failure treated by cardiologists, internists, family physicians, and other physicians. Am Heart J 2000; 139:491-6. Rost K, Zhang M, Fortney J, Smith J, Coyne J, Smith GR Jr: Persistently poor outcomes of undetected major depression in primary care. Gen Hosp Psychiatry 1998; 20:12-20.
Ryan DH: Misdiagnosis in dementia. Intl J Geriatr Psychiatry 1994; 9:141-7. Safran DG: Defining the future of primary care. Ann Intern Med 2003; 138:248-55. Simon GE, Goldberg D, Tiemens BG, Ustun TB: Outcomes of recognized and unrecognized depression in an international primary care study. Gen Hosp Psychiatry 1999; 21:97-105. St. Peter RF, Reed MC, Kemper P, Blumenthal D: Changes in the scope of care provided by primary care physicians. N Engl J Med 1999; 341:1980-5. Stafford RS, Saglam D, Cuasino N, Starfield B, Culpepper L, Marder WD, Blumenthal D: Trends in adult visits to primary care physicians in the United States. Arch Fam Med 1999; 8:26-32. Temte J, Grasmi9ck M, Barr J, Kunstman J, Jaeger A, Beasley J: Encounter problem density in primary care: a better measure of complexity? Presented at the annual meeting of the North American Primary Care Research Group on October 20-23, 2007 in Vancouver, British Columbia. Thompson C, Ostler K, Peveler RC, Baker N, Kinmonth AL: Dimensional perspective on the recognition of depressive symptoms in primary care. Br J Psychiatry 2001; 179:317-23.
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minutes in brief
Highlights from the TAFP Board of Directors, March 3, 2012 The Texas Academy of Family Physicians Board of Directors met on Saturday, March 3, 2012, to consider reports and recommendations from TAFP’s committees, commissions, and sections. Below are the highlights of the meeting, which included a robust discussion of the goals for the next Texas legislative session and the launch of TAFP’s new website and rebranding. Executive Committee
Nominating Committee
The Executive Committee had two recommendations for the Board of Directors to review. The first recommendation was that TAFP’s Section on the Medical Home be absorbed into the Commission on Health Care Services and Managed Care. The work of the section— primarily guiding the organization to distribute information and resources to the membership about the patient-centered medical home—is work that could be done by the commission.
The Nominating Committee proposed the following slate of officers for 2012-2013:
The second recommendation was that TAFP form a new section to address the needs of family physicians in large group practices. More family physicians are seeking employment or aligning with large, clinically integrated group practices. The Executive Committee believes it would be beneficial to the Academy to provide a forum for family physicians practicing in these settings. This would provide an opportunity to discuss issues and provide feedback on the value of their membership with TAFP. The section will report to the Commission on Membership and Member Services. Finance Committee The Finance Committee recommended that TAFP adopt a policy to allow the CEO the authority to expend up to $10,000 on capital expenditures provided that he notify the TAFP Executive Committee within 10 days and report to the Finance Committee at the next meeting. TAFP owns its headquarters and leases office space to other companies. When maintenance issues arise, management needs the ability to take immediate action for certain capital expenditures. The Finance Committee also recommended that the Board of Directors approve a revised budget for fiscal year 2012. Adjustments were made after the Academy’s management reviewed the income and expenses as of Jan. 31, 2012.
President-elect: Clare Hawkins, M.D. Vice President: Ajay Gupta, M.D. Treasurer: Dale Ragle, M.D. Parliamentarian: Tricia Elliott, M.D. Commission on Academic Affairs The Commission on Academic Affairs requested that TAFP automatically appoint family medicine department chairs at Texas medical schools, residency program directors, and clerkship directors to the Commission on Academic Affairs. The commission hopes to increase awareness, interest, attendance, and participation. Commission on Continuing Professional Development The commission approved program chairs. Rebecca Hart, M.D., (formerly Rebecca Gladu, M.D.) will serve as chair for 2012 Primary Care Summit - Houston; Clare Hawkins, M.D., for Primary Care Summit Dallas; Sharon Hausman-Cohen, M.D., for 2013 C. Frank Webber Lectureship; and Jennifer Culver, M.D., for the 2013 Annual Session and Scientific Assembly. Commission on Core Delegation The commission discussed the work of the various AAFP commissions. The commission also discussed the details of the campaign for Lloyd Van Winkle, M.D., for the AAFP Board of Directors. Commission on Health Care Services and Managed Care The commission recommended that TAFP hold a town hall meeting on various clinically integrated practice models at the next Annual Session. Commission on Legislative and Public Affairs Tom Banning discussed the past Texas legislative session and actions
the Academy is taking in the interim and election cycle to positively position the specialty. He introduced Charles Bell, M.D., former deputy commissioner of the Texas Health and Human Services Commission, who updated the commission on his work to develop policy recommendations to be presented to elected officials and crafted into potential legislation in the upcoming 83rd Texas Legislature. Commission on Membership and Member Services The commission discussed membership statistics, the re-election report, and resident and student recruiting. The commission also discussed the new physician webinar and retention program the Academy has undertaken. Section on Special Constituencies The section organized a service project in conjunction with the TAFP Foundation. During the 63rd Annual Session and Scientific Assembly in Austin, TAFP will collect donations for the People’s Community Clinic. Donations can be made directly to the TAFP Foundation, on the Annual Session registration form, or at the Annual Session registration desk. The section selected Linda Siy, M.D., as the recipient of the TAFP Special Constituency Leadership Award. Section on Medical Students The section on medical students recommended that TAFP create a new student officer position: the TAFP FMIG Coordinator. This will give the students a better platform of making sure that AAFP’s FMIG information gets dispersed throughout the Texas medical schools. The section held their elections for the 2012-2013 student officer positions. The new officers are: Chair: Rebecca Divers Chair-elect: Jerry Abraham Secretary: Jennifer Roncallo TAFP Board of Directors: Carlos Medina TAFP Board of Directors Alternate: Stella Benavides National Conference Delegate: Troy Russell National Conference Alternate Delegate: Shiv Agarwa FMIG Coordinator: A. Jade Booher Section on Resident Physicians The Section held their elections for the resident officer positions. The new officers are: Chair: Irvin Sulapas, M.D. Vice Chair: Diana Mercado, M.D. Secretary: Molly Hoss, M.D. National Conference Delegate: Linda May, M.D.
National Conference Alt. Delegate: Abiodun Okin, M.D. Delegates to the TAFP Board of Directors: Alfonso Guzman, M.D., and Justin Squyres, M.D. Alternate Delegates to the TAFP Board of Directors: Laura Houston, M.D., and Richel Avery, M.D. Proposed Amendment to TAFP Bylaws The proposed amendment to the TAFP Bylaws is in accordance with the TAFP Bylaws, Chapter XIV, Amendment of Bylaws. An affirmative vote of at least two-thirds of the members present and voting at the annual business meeting shall constitute adoption. If you would like to receive a complete copy of the TAFP Bylaws, contact Kathy McCarthy at the TAFP office at (512) 329-8666, ext. 14. Chapter VI, Section 1 SECTION 1 Active Members - Active Members. Election to active membership shall be for a maximum period of three (3) years, at the expiration of which term the member shall be eligible for re-election. No member shall be re-elected to membership who is not in good standing at the time of their re-election and has not fulfilled the continuing medical education requirements. Former active members who apply for membership less than two years after having ceased to be an active member must provide evidence they have earned the requisite 100 credits of continuing medical education acceptable to the Board; except that such an applicant who was a resident member in good standing and automatically upgraded to active status upon completion of residency training but never paid dues as an active member shall not be required to satisfy this continuing medical education requirement upon reapplication within two years of completion of residency training. Members of this Academy shall be in good standing in their component chapter and shall have paid all appropriate dues and fees. A member may join or transfer his/her membership to another component chapter that offers a closer community of interest. Initial application for membership may be made directly to the component chapter with which the member desires affiliation. Transfer of existing membership, however, must be approved first by the member’s current chapter before the application for transfer may be considered. Recommendation of the Bylaws Committee: FOR Action of the Board of Directors: The Board of Directors recommended adoption of this proposed amendment at the March 3, 2012, meeting. www.tafp.org
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perspective
Patient-centered medical home: Are we or aren’t we? By David W. Bauer, M.D.
when is a patient-centered medical home not a patientcentered medical home? In my practice, the answer is “every day.” In 2009 we received NCQA’s designation as a Level 3 PCMH. To achieve this, our physicians had to document ways in which our patients had enhanced access to our practice, provide examples of how we use evidence-based guidelines to provide quality care, demonstrate the means by which we coordinated care across time and space, and a number of other measures. We do, in fact, do those things every day. What we don’t do, is do all of them for every single patient, every single day. Consider the analogy of a patient with diabetes whose hemoglobin A1c is 6.9. We would say that the patient’s diabetes is well controlled and congratulate the patient. But there are many ways that a patient could achieve this value. One would be to have very little fluctuation of her glucose from hour to hour. Another would be for the patient to drop into the 40s overnight, and climb to 200 immediately after meals. The hemoglobin A1c is an average, and doesn’t factor in variation. For years, decreasing variation has been the mantra of those working to improve quality, increase efficiency, and decrease medical errors in the hospital setting. As we migrate toward a new model of health care in this country—the PCMH—it would be valuable to embrace this concept in our offices as well. In the portions of our practice where we have fully implemented a PCMH model, we can point to positive outcomes. Several years ago we created a primary care behavioral health program. In this physicianled, team-based approach to treating depression and anxiety in the family physician’s office, we have outcomes that exceed those reported in the literature. The physician identifies patients with depression and/or anxiety through the use of standardized instruments, and implements whatever pharmacologic therapy is appropriate. He or she also introduces the patient to our care manager, who meets with the patient (by e-mail, phone, or in person) weekly. This allows the care manager to identify the patient who is troubled by side effects of medication, whose depression is worsening, who has a new stressor, etc. That information is given back to the physician, who can then intervene quickly. Both the physician and care manager interact with a psychologist, and we also pay for a few hours a week of a psychiatrist’s time for consultation on the more challenging patients. Using objective measures of depression in a team-based model of care collected over a three-year period, our statistics show 39 percent of patients are in full clinical remission, and 50 percent had at least a 50 percent drop in their symptom score after 10 weeks of this model of care. This is twice the rate generally seen in the literature. We apply the principles of a PCMH to other aspects of our practice as well. We do team-based care for patients with diabetes
(physician, Pharm.D., and dietician team), osteoporosis (physician, nurse, and dietician), pregnant women who are obese (obstetrician, sports medicine physician, dietician, and local gym). All patients benefit from our advanced electronic medical record system, our extended office hours (patients have access to at least one of our physicians 79 hours a week), open access, etc. So, in that sense, we offer aspects of the PCMH to each patient. But, what about the patient with diabetes whose ophthalmologist never sends his notes (despite pleas from the patient and me), so I never can determine if the patient has retinopathy? What about the patient who could benefit from a visit with our dietician, but whose insurance will not cover the visit since the patient does not yet have diabetes? I have let those patients down. I haven’t lived up to the promise of a PCMH to them. What are we to do? How can we reduce variation? How can we deliver on the huge promise and potential that a true medical home embodies? The answer, like the problem, is going to be complex and multifactorial. Clearly, the universal use of robust EMRs is an absolute necessity. So are local and regional health information exchanges. We need to rethink the timehonored model of the office visit in which the physician extracts a history from the patient. The technology exists today to allow patients to enter portions of their history themselves. Not only is this a more effective use of the limited face-to-face time of most office visits, but it makes the patient an active participant in his or her care—a cornerstone of the PCMH. Finally, in order to deliver on our promise we will have to share resources. The vast majority of family doctors in this state could not afford to have a full-time dietician, patient educator, patient navigator, therapist, etc. But, it is possible for practices within a geographic cluster to band together to support such team members. Patient-centered medical homes will transform the care of our patients. The promise is there. The principles are there. And, the practices are there—more and more family physicians’ practices are receiving the PCMH designation. But, so far we have done the easy part. The harder part—being a medical home for every patient every day—is going to take more than a seal from NCQA. The evolutionary changes implemented need to serve as a springboard for revolutionary ones. It is only at that point that all of us can become what we want to be—a true medical home for every single patient, every single day.
How can we deliver on the huge promise and potential that a true medical home embodies? The answer, like the problem, is going to be complex and multifactorial.
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David W. Bauer, M.D., practices family medicine at Physicians at Sugar Creek, and is the residency program director at Memorial Family Medicine Residency Program in Sugar Land, Texas.
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