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Fam Pract Manag. 2000;7(1):22-24

IOM calls for system-wide changes to prevent errors

Calling medical errors “one of the nation's leading causes of death and injury,” the Institute of Medicine (IOM) of the National Academies recently issued a report outlining its recommendations for reducing errors.

Between 44,000 and 98,000 people die each year in U.S. hospitals, and more than 7,000 people die each year due to medication errors both in and out of the hospital, says the report. “These stunningly high rates of medical errors … are simply unacceptable in a medical system that promises first to ‘do no harm,’” said William Richardson, PhD, chair of the IOM committee that wrote the report and president and CEO of the W.K. Kellogg Foundation.

The report blames the errors not on human recklessness but on “basic flaws in the way the health system is organized.” It cites practices such as stocking full-strength drugs that are toxic unless diluted, illegible writing in medical records and lack of coordination of care.

The committee has set a minimum goal of 50 percent reduction in errors over the next 5 years. Its recommendations include the creation of a national patient safety center, the establishment of a national system for reporting medical errors, and the cultivation of an organizational culture that makes safety a top priority without attaching blame to individuals.

“You don't get to safe systems that have human beings in them by yelling at them or asking them to try harder. You need to engineer the work environment so that normal human limits are respected,” said Don Berwick, MD, member of the IOM committee and president of the Institute for Healthcare Improvement, in the Dec. 5 New York Times.

Following the IOM report, President Clinton ordered all federal agencies that provide or pay for health care services to evaluate and implement methods to reduce medical errors.

Medicare finalizes 2000 fee schedule

HCFA recently announced its final rule for the 2000 Medicare Physician Payment Schedule. The summary below highlights some of the changes, but you can consult the Nov. 2, 1999, Federal Register for a more thorough explanation.

  • The conversion factor used in the calculation of physician payments has increased to $36.6137. (Last year's was $34.7315.)

  • Payment for physician practice expenses is still in transition, from being based on historical charges to being based on the actual resources used. For 2000, HCFA will use a 50-50 blend of the two methods.

  • Resource-based malpractice relative value units are being implemented on an interim basis and will be based on actual malpractice premium data.

  • Nurse practitioner qualifications for Medicare payment have been revised, and they include clarification on state authorizations and Medicare billing number assignments.

  • Payment for pulse oximetry, temperature gradient studies and venous pressure will now be bundled into evaluation and management (E/M) services.

  • Payment may be made for a male beneficiary 50 years old or older for both an annual digital rectal examination (DRE) (HCPCS G0102) and an annual prostate-specific antigen test (HCPCS G0103). You may not use the DRE code with any covered E/M service performed on the same date.

New physicians frustrated by coding, managed care, journal deluge

Medical school and residency may prepare family physicians for diagnosing and treating clinical problems, but it doesn't always prepare them for other aspects of their professional lives. According to a “New Physician Survey” recently commissioned by the AAFP, new family physicians' number one frustration is coding and documentation, followed by managed care and “keeping up with journals.” Time management and organizational politics round out the top five.

Uncertainty continues as health systems seek workable models

An ongoing survey of 12 local health care systems across the United States suggests that the degree of turmoil and change within the industry will only continue. A leading cause, according to the survey, is consumer discontent, which is prompting many health care organizations to rethink or abandon core strategies.

“The backlash against managed care is leading to less management of care and is threatening the viability of vertically integrated health systems,” said Paul B. Ginsburg, PhD, president of the Center for Studying Health System Change (HSC), at a recent conference presenting the HSC survey findings.

The situation is no less tumultuous for physicians, who “are continuing to search for effective organizational forums despite the very painful stumbles that they have been through in the last few years,” he said, referring to the failures of physician practice management companies and physician-hospital organizations.

The survey suggests that organizations that are physician-led and less costly to operate, such as independent practice associations and management service organizations, may be gaining favor in the market.

Residents can unionize — and strike

A Nov. 26 ruling by the National Labor Relations Board (NLRB) gives residents and interns at private hospitals the right to unionize under federal law. Until now, residents and interns at nongovernment-owned hospitals have not been eligible for unionization because of a 1976 decision that classified them as students, not employees.

Hospital administrations fear that potential union demands could hurt already ailing hospitals. Of particular concern is the right to strike. “We think [the NLRB] made the wrong decision,” said Joseph Keye, general counsel for the Association of American Medical Colleges in the Nov. 30 Washington Post. “It's bad for both education and labor relations.”

Approximately 10 percent of the nation's 100,000 residents already belong to the Committee of Interns and Residents (CIR), an affiliate of the 1.3 million-member Service Employees International Union and the nation's only major residents' union. So far, their actions have been fairly modest, such as working to decrease residents' hours to about 80 per week. The NLRB's decision is expected to intensify unionization efforts as residents try to gain some control over their working conditions and salaries.

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“United Healthcare has served us all very well because they've neutralized the cost question and essentially ratified the moral question of who should decide the kind of medical care that a patient is going to get — the doctor or some faceless, nonelected, nondegreed, unwanted practitioner of medicine.”

Rep. John D. Dingell, D-Mich., describing the relevance of United Health-care's decision to do away with utilization review. United's decision was based, in part, on its findings that reviewing physicians' treatment decisions resulted in few changes in care but millions of dollars in administrative costs.

Physician recruitment still friendly to family practice

Specialty physician searches outnumbered primary care physician searches over the past 12 months, according to the “1999 Review of Physician Recruitment Incentives” from Merritt, Hawkins & Associates. This is the first time in the survey's history that primary care physician searches have not been on top; however, family practice remained the most highly recruited specialty overall.

Average income offerings for family physicians were $136,000. Ninety percent of all offers included malpractice benefits, 83 percent included continuing medical education, 71 percent included disability and retirement benefits, 34 percent included signing bonuses and 25 percent included educational loan forgiveness.

The survey is based on more than 1,800 physician searches performed by the firm.

Doctors may report patients who are driving risks

Physicians who contact their Department of Motor Vehicles to inform them of patients who may be unsafe drivers because of their medical conditions now have the ethical blessing of the AMA. At its interim meeting in December, the AMA adopted this new policy, which in effect makes public safety a greater priority than patient confidentiality.

But not all physicians agree with the decision. In debate before the vote, some delegates argued that the risk of losing driving privileges would discourage some patients from seeking treatment. “This will change us from physicians to policemen,” said New Jersey physician Walter J. Kahn, MD, in a Dec. 8 article from the Associated Press.

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