American Diabetes Association revises diabetes guidelines

The American Diabetes Association (ADA) has revised clinical practice recommendations for diabetes diagnosis to promote hemoglobin A1c as a faster, easier diagnostic test that could help reduce the number of undiagnosed patients and better identify patients with prediabetes. The new recommendations are published in the January supplement of Diabetes Care.

“There are several revisions and updates included in the American Diabetes Association’s 2010 Clinical Practice Recommendations that will potentially impact how health plans care for the many individuals with type 1 and type 2 diabetes and those at risk for diabetes,” says Richard M. Bergenstal, MD, president, Medicine and Science, American Diabetes Association and Executive Director, International Diabetes Center. “A significant change is that the ADA now recommends the A1C test can be used to diagnose diabetes or identify those at high risk for developing diabetes. Patients can prevent complications and suffering, and health plans can minimize long costs if diabetes is detected and treated effectively early or if diabetes can be prevented.

The A1c test, which measures average blood glucose levels for a period of up to 3 months, was previously used only to evaluate diabetic control with time. An A1c level of approximately 5% indicates the absence of diabetes, and according to the revised evidence-based guidelines, an A1c score of 5.7% to 6.4% indicates prediabetes, and an A1c level of 6.5% or higher indicates the presence of diabetes.

Extensive revisions to the section “Diabetes Self-Management Education” are based on new evidence. The goals of diabetes self-management education are to improve adherence to the standard of care, to educate patients regarding appropriate glycemic targets, and to increase the percentage of patients achieving target A1c levels.

“The 2010 Standards or Medical Care present new data to emphasize how important it is to teach diabetes self-management so health plans need to be sure they have a recognized education program in place that facilitates patient centered team care,” Bergenstal says. “There is also new evidence reviewed that will give health plans information on effective strategies to improve diabetes care and develop treatment targets in the outpatient and inpatient setting. Educating patients and providers that good diabetes care means control of blood glucose (while avoiding hypoglycemia and excessive weight gain), as well as controlling blood pressure and cholesterol is critical to preventing complications. Effective and appropriate use of new technologies like insulin pump and continuous glucose monitoring are also reviewed in light of new studies released in the last year and health plans should review this data to be able to effectively communicate with patients and providers.”

8 Top Hospital and Health System Trends of the Past Decade

1. Loosened cost controls. HMOs in the late 1990s had successfully slowed growth in healthcare spending, but by the end of that decade they had come to be regarded as heartless conservators of the bottom line. Managed care’s tight controls began to loosen and “the negotiating power slipped back into the hands of the providers,” says Dick Clarke, president of the Healthcare Financial Management Association. Healthcare costs again began increasing faster than the general rate of inflation. “It’s not clear yet how much of that will change if providers come under more pressure to contain prices,” he says. 

2. Healthcare IT. Healthcare information technology, still rough around the edges in 2000, became a major force in hospital operations by the end of the decade, says Michael Rowan, COO and executive vice president of Catholic Health Initiatives in Denver. Innovations like computerized physician order entry and electronic medical records have been shown to improve safety as well as efficiency. Now, thanks to billions of dollars in incentives in the 2009 HITECH legislation, healthcare IT holds the promise of becoming virtually universal in the next few years. But Mr. Rowan reports that HITECH funds will pay for only about a quarter of the cost of the new technology. 

3. Patient safety movement. At the start of the decade, hospitals were just beginning to hear word of one of the most influential reports in the history of U.S. healthcare: “To Err Is Human: Building a Safer Health System,” published in Nov. 1999 by the Institute of Medicine. It concluded that from 44,000- 98,000 people die annually — the equivalent of 10 fully loaded 757 commercial airliners crashing each week, the report stated — due to errors in inpatient hospital treatment.

As a result, “hospitals started to get much more serious about quality and safety,” says Mr. Clarke at HFMA. The industry embraced continuous quality improvement, adds Thomas Dolan, president and CEO of the American College of Healthcare Executives. “Everybody realized that we have to constantly improve quality and it actually lowers costs because it reduces waste,” he says.

4. Physician entrepreneurialism. Many physicians became entrepreneurs, investing in ASCs, imaging centers and specialty hospitals as a way to supplement declining income due to lack of increases in reimbursements and become more efficient. The trend, however, put physicians into conflict with hospitals, who were concerned about losing market share to the leaner, physician-run organizations. By the end of the decade, it seemed that hospitals and regulators had blunted the trend.

“The ban on physician-owned hospitals in the health reform legislation signals the decline of the entrepreneurial physician,” says Nicholas Wolter, MD, a former MedPAC commissioner and CEO of the Billings (Mont.) Clinic. However, ASCs seem to have become a permanent fixture in U.S. healthcare, offering discounts too big for payors to pass up. 

5. Healthcare consumerism. “The future of market-oriented health policy and practice lies in ‘managed consumerism,’ a blend of the patient-centric focus of consumer-driven healthcare and the provider-centric focus of managed competition,” declared Jamie Robinson, a professor of health economics at the University of California, Berkeley, School of Public Health, in 2005 in the journal Health Affairs.

With the decline of HMOs, consumer-driven healthcare became a new way to contain costs. High deductible plans, with or without tax-free health savings accounts, would make patients cost-conscious consumers. Ratings of doctors and hospitals, from HealthGrades to CMS’ Hospital Compare site, would aid patients in choosing the best providers. Retail clinics opened to serve these new consumers. Hospitals developed a new fascination with patient satisfaction surveys. Brand-new hospitals lavished spending on patient-friendly design features, such as single rooms, sunlit atriums and concierge services, and these features seemed to shift market share. 

6. Shortages of healthcare personnel. In July 2007, the American Hospital Association reported 116,000 open positions for registered nurses in hospitals, and the existing RN workforce was aging. Mr. Rowan at Catholic Health Initiatives observes that the recession has erased the shortage for now, at least, as RNs were forced back into the workforce or into full-time work as family income fell.

Physician shortages also emerged. In a dramatic about-face at the beginning of the decade, the federal Council on Graduate Medical Education abandoned its long-held forecast of a physician surplus and predicted a shortage of 85,000 physicians by 2020. Since then, medical schools have been substantially increasing class sizes, but Congress has not removed a cap on the number of Medicare-funded graduate medical education positions for physicians that has been in place since 1997.

“Current evidence suggests that the United States is headed toward an aggregate shortage of physicians,” the Association of American Medical Colleges declared in 2009. “Given the extended time required to increase U.S. medical school capacity, and to educate and train physicians, the nation must begin now to increase medical school and GME capacity to meet the needs of the nation in 2015 and beyond.”

7. Accountable health organizations. While entrepreneurial physicians continued to spin off from hospitals throughout the decade, Dr. Wolter, the former MedPAC commissioner, says an opposing trend also emerged. Many young physicians were eagerly becoming employees. Accountable health organizations such as Mayo Clinic, the Cleveland Clinic and Geisinger Health System thrived by closely aligning hospitals and doctors to make care more efficient and effective.

Mr. Rowan at Catholic Health Initiatives says accountable health organizations seemed to be taking a lesson from the ASC playbook. Incentivizing physicians can make healthcare more efficient. But he adds that the trend is not easy for hospitals. “Many hospitals have no expertise in running practices,” Mr. Rowan says. “We’re hospital people, not group management people.” Hospitals used to hire doctors merely to generate business. Now, he says, “hospitals want doctors to take financial responsibility for outcomes.”

8. Recession. “The decade will be known for the financial turmoil that came at the end,” says Mr. Clarke of HFMA. In March 2009, Thomson Reuters reported that the median profit margin of U.S. hospitals has fallen to zero percent. Hospitals tightened their belts and many of them ended the decade solidly in the black. But the numbers of non-paying patients are still high and many leaders like Clarke believe we are entering an era of having to do more with less.

2010 CPT Changes for Paravertebral Facet Joint Injections & Guidance

CPT copyright 2008 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

NCCI’s most recent edits include significant changes for coding and billing facet joint injections. As of 2010, CPT codes for facet joint injections will include guidance for locating the injection site and will limit the number of levels that can be billed at three per day, according to Lynn Kuehn MS, RHIA, CCS-P, FAHIMA, a healthcare coding consultant with Murer Consultants.

Previous codes assigned for paravertebral joint injections did not include guidance that is used to help the physician locate the injection site, so guidance was billed separately for fluoroscopy (CPT 77003) or CT guidance (which actually did not have a code). Now, claims will be rejected if they include separate codes for the injection and guidance, according to Ms. Kuehn.

Codes for paravertebral facet joint injections, with guidance, are as follows:

•    Cervical or thoracic injections:
o    CPT 64490 — First or single level, with fluoroscopy or CT guidance
o    CPT 64491 — Second level, with fluoroscopy or CT guidance
o    CPT 64492 — Third and any additional levels, with fluoroscopy or CT guidance
•    Lumbar or sacral injections:
o    CPT 64493 — First or single level, with fluoroscopy or CT guidance
o    CPT 64494 — Second level, with fluoroscopy or CT guidance
o    CPT 64495 — Third and any additional levels, with fluoroscopy or CT guidance

According to Ms. Kuehn, physicians who do not use guidance to perform facet joint injections cannot use these CPT codes and instead must use musculoskeletal codes, such as codes for tendon sheath or trigger point injections (CPT 20550-20553).

Ms. Kuehn also says that some physicians may choose to use ultrasound guidance for facet joint injections. In those cases, the injections should be billed using Category III codes 0213T-0218T, which mirror CPT 64490-64495.

The information provided should be utilized for educational purposes only. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.

CMS Issues Corrections to 2010 HCPCS Code

The Centers for Medicare and Medicaid Services have issued corrections to its list of 2010 HCPCS codes, including new approved procedures for ASCs, description changes and coverage changes, which went into effect Jan. 1, 2010.

The following procedures have been designated “YY,” or safe to be performed in an ambulatory surgery setting:

• A9581 — Injection, gadoxetate disodium, 1 mL
• A9582 — Iodine i-123 iobenguane, diagnostic, per study dose, up to 15 millicuries
• A9583 — Injection, gadofosveset trisodium, 1 mL

The following codes had changes made to the CMS long description:

• C8923 — Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes m-mode recording, when performed, complete, without spectral or color doppler echocardiography
• C8924 — Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes m-mode recording, when performed, follow-up or limited study)
• C8928 — Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes m-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmocologically-induced stress, with interpretation and report
• L8680 — Implantable neurostimulator electrode, each

The following codes have had coverage changed back to “I,” according to the 2010 corrections:

• S2118 — Metal-on-metal total hip resurfacing, including acetabular and femoral components
• S2270 — Insertion of vaginal cylinder for application of radiation source or clinical brachytherapy (report separately in addition to radiation source delivery)
• S3628 — Placental alpha microglobulin-1 rapid immunoassay for detection of rupture of fetal membranes
• S3711 — Circulating tumor cell test
• S3860 — Genetic testing, comprehensive cardiac ion channel analysis, for variants in 5 Major cardiac ion channel genes for individuals with high index of suspicion for familial long qt syndrome (LQTS) or related syndromes
• S3861 — Genetic testing, sodium channel, voltage-gated, type v, alpha subunit (SCN5A) and variants for suspected brugada syndrome
• S3862 — Genetic testing, family-specific ion channel analysis, for blood-relatives of individuals (index case) who have previously tested positive for a genetic variant of a cardiac ion channel syndrome using either one of the above test configurations or confirmed results from another laboratory
• S9433 — Medical food nutritionally complete, administered orally, providing 100 percent of nutritional intake

Read the CMS’s correction file for the 2010 HCPCS codes.

Some Ohio Physicians Dropping Medicare

Some gynecologists in the Columbus area are dropping Medicare patients due to low payments, according to a report by the Columbus Dispatch.

A spokesman for the Ohio State Medical Association said dropping Medicare has been a growing trend due to stagnant fees since 2001 but still only a small number of physicians are doing so.

The exodus would be much larger, however, if Medicare physician payments were automatically cut by 21 percent on March 1, which would happen if Congress does not postpone the cut, as it has done every year for the past eight years.

Read the Columbus Dispatch’s report on Columbus Medicare.

Healthcare Trust of America Acquires Colorado Medical Office Building, Surgery Center

Healthcare Trust of America, based in Scottsdale, Ariz., has acquired Hampden Place Medical Center in Englewood, Colo., for $18.6 million, according to an HTA news release.

Hampden Place houses an ambulatory surgery center, medical imaging and physiotherapy facilities, and medical offices for orthopedic, hematology-oncology and related-physician practices, according to the release. The facility was developed in conjunction with local physicians and HCA HealthOne Hospital System.

Read the release about HTA’s acquisition of Hampden Place Medical Center.

New Ophthalmology Chairman Named at University of Nebraska

Tom Hejkal, MD, PhD, has been named McGaw Memorial Chairman of the University of Nebraska Medical Center Department of Ophthalmology and Visual Sciences in Omaha, Neb., according to a UNMC news release.

Dr. Hejkal succeeds Carl Camras, MD, who passed away in April, according to the release.

Dr. Hejkal joined the UNMC faculty in 1994 and has served as residency program director for the department since 1996 and as vice chairman for clinical operations since 2007. According to the report, he earned his PhD in oceanography from Florida State University and his medical degree from UNMC.

Read the UNMC release on Dr. Tom Hejkal.

Appeals Court Rules HHS Not Required to Release Medicare Claims Data Under Freedom of Information Act

A three-judge panel from the 11th U.S. Circuit Court of Appeals has ruled that the U.S. Department of Health and Human Services is not required under the Freedom of Information Act to provide Medicare claims data to a private company, according to a report by American Medical News.

Birmingham, Ala.-based Real Time Medical Data sought to provide hospitals, physicians’ offices and other healthcare organizations access to Medicare marketing data, including physician names, addresses and information about the type and volume of procedure they perform, according to the report.

In 2008, the Northern District Court of Alabama issued a permanent injunction ordering HHS to release the claims data for Alabama and three surrounding states. The U.S. Department of Justice and the AMA appealed the decision.

In its ruling, the Circuit Court cited a 1979 case, Florida Medical Assn. v. Dept. of Health Education & Welfare. In the case, the Florida State Medical Association sued the Department of Health Education & Welfare when it planned to release of list of all physicians who treated Medicare patients and their income from the program. The court eventually ruled in favor of the physicians, prohibiting the DHEW from releasing the list.

Read the American Medical News’ report on the release of Medicare claims dat

CMS Issues Corrections to the 2010 Physician Fee Schedule

The Centers for Medicare and Medicaid Services has announced corrections to the 2010 Physician Fee Schedule that includes changes to the Medicare anesthesia conversion factor, which went into effect on Jan. 1, 2010, according to a news release from the American Society for Anesthesiology and information from CMS.

The correction takes into consideration calendar year 2010 anesthesia practice expense revisions, according to the ASA release.

The nationwide unadjusted conversion factor for anesthesia services provided between Jan. 1 and Feb. 28, 2010, will be $21.114, according to the release. Anesthesia practices located in Alaska will receive the highest conversion factor at $29.51, whereas practices in Puerto Rico and the Dakotas will receive the lowest at $17.66 and $18.95, respectively. 

A list of conversion factors by locale is available here.

Additionally, CMS corrected the 2010 conversion factor across specialties, fixing a technical error in adjusting relative value units, reflective of the agency’s policy with consultation codes, according to CMS. 

Here is a list of some of the new 2010 payments under the corrected schedule:
•    CPT 27130 (Total hip arthroscopy) (facility) — $1,082.21
•    CPT 27447 (Total knee arthroscopy) (facility) — $1,157.72
•    CPT 43239 (Upper GI endoscopy, biopsy) (facility) — $134.00
•    CPT 66984 (Cataract surgery w/ IOL, I stage) (facility) — $548.77

A complete listing of corrected 2010 payments can be found here. 

After Feb. 28, CMS will impose a 21 percent Medicare payment cut across all medical practices, which will directly affect the payments and conversion factors.

For more information on the 2010 Physician Fee Schedule, click here. 

Read the ASA release on the revised 2010 Medicare anesthesia conversion factors. 

Read the CMS transmittal on the 2010 Physician Fee Schedule. 

Read the Federal Register article on corrections to the 2010 Physician fee schedule (pdf).

As Senate Considers More Medicare-Funded Residency Slots, Hospitals Not Filling Existing Slots

As the Senate considers adding more Medicare-funded residency positions to meet future needs for physicians, the Association of American Medical Colleges reports that about 1,500 currently funded positions go unfilled, according to a report by Bloomberg.

Hospitals that don’t fill the slots can no longer provide the supervision or the hands-on experiences that are required, said a workforce expert at the AAMC. Experts added that the current number of residency slots can “nowhere near” meet future needs and even if all slots could be filled and new ones were added, it would take years for physicians to get through the training pipeline.

While many medical schools have increased their class sizes to accommodate future demand, Harvard Medical School has kept enrollment the same, assuming that nurse practitioners, physician assistants and other non-MDs, rather than doctors, would fill in the gap.

Read Bloomberg’s report on hospital residency slots.

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