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Fam Pract Manag. 2000;7(8):24-25

PPO to reimburse for e-mail consultations

An Illinois PPO, First Health Group Corp., says it will soon be the first managed care organization to reimburse physicians for Internet consultations with chronic-care patients. The organization does not expect the consultations to cut down on office visits from chronic-care patients, but it hopes the need for acute hospitalizations will decrease.

“Patients with chronic conditions tend to benefit most from regular physician contact to catch early signs of potentially acute episodes. Online communication is an effective way for these patients to communicate with their physicians to catch these early warning signs,” said Scott P. Smith, MD, national medical director for First Health.

For an online consultation to be reimbursable, the patient must be enrolled in the PPO's chronic-care support program, and the patient and physician must agree to handle consultations online. The physician can then be reimbursed $25 for each online communication that involves clinical content, such as answering patients' questions or reviewing patients' daily blood sugar readings.

Goodbye capitation

Aetna U.S. Healthcare has announced that by January it will completely phase out capitation for its 1,800 primary care physicians in Connecticut. The change is intended to improve physician retention and recruitment and simplify administration of the plan's HMOs, reports the Aug. 10 Hartford Courant. Earlier this year, the insurer announced it would phase out capitation in Texas and Virginia for primary care doctors with 100 or fewer Aetna patients.

Goodbye California?

California doctors pinched by low managed care rates are finding little reason to stay in the golden state. Since 1993, the state's average capitation rate has sunk 35 percent while its cost of living has increased 25 percent, according to the July 24 East Bay Business Times. In the last 10 years, California's doctor-to-patient ratio has dropped four places in state comparisons.

Rx costs for seniors

Annual prescription drug spending per senior citizen has doubled since 1992 and is expected to skyrocket, according to a report from Families USA, a non-profit health care advocacy organization. Seniors spent an average of $559 on prescriptions in 1992, will spend $1,205 in 2000 and are projected to spend $2,810 in 2010 — a jump of 403 percent.

Patient appeals

Only six percent of patients who have experienced conflicts with their health plans have taken advantage of state laws that allow them to file a formal appeal, according to a recent survey by the Kaiser Family Foundation and Consumer Reports. Instead, almost three-quarters of the patients contacted a plan representative or their physicians for help.

The new face of HCFA

Acknowledging that it must “increase the trust level” of physicians, the Health Care Financing Administration (HCFA) has undertaken a customer service initiative focused on “increasing the effectiveness of medical review and provider enrollment.” The agency promises a more user-friendly enrollment application, a publication that will explain HCFA's program integrity activities in plain, easily understandable language and a toll-free telephone line that providers may call with questions.

On second thought…

Oxford Health Plans has taken an unconventional approach to dealing with physicians it contends upcoded claims. Rather than downcoding the claims, the plan paid them and now is demanding refunds. One physician was told he owed $87,041 and that if 75 percent of the payment was not made within 10 days, Oxford would bring the matter to arbitration. The Medical Society of the State of New York, which estimates about 300 physicians received the threatening letters, has filed a complaint with the state Department of Health.

30 minutes guaranteed

Emergency health care is being delivered piping hot in Detroit. According to the Aug. 2 Detroit News, the emergency department at Oakwood Hospital is now guaranteeing patients service within 30 minutes. Those who wait longer can expect to receive an apology from the doctor and free movie passes. Now that's something we haven't seen on “ER.”

Practice Management Tips

When antibiotics aren't the answer

If a patient demands an unnecessary antibiotic prescription, take these five steps to make him or her understand why antibiotics aren't always the answer:

  1. Explain your exam findings to the patient to show you've been thorough.

  2. Tell the patient that, based on your findings, you don't think antibiotics will help, and briefly explain why.

  3. Propose treatment alternatives. (You can use the Centers for Disease Control and Prevention's non-antibiotic prescription pad, which can be downloaded at

  4. Review the non-antibiotic plan with the patient, and explain how similar plans have been successful for other patients.

  5. Encourage the patient to stay in contact with you, and tell him or her when the symptoms should clear up. Also, let the patient know you'll reconsider the antibiotic request if certain problems arise.

— Goldman EL. Getting patients to swallow the “no antibiotics” pill. Fam Pract News. May 15, 2000:13.

Honesty is the best policy

Full and honest disclosure, including an apology to the patient, is generally the most appropriate action following a medical error; however, if the error is inconsequential or disclosure would cause undue harm to the patient, nondisclosure may be ethically appropriate. Even without patient disclosure, acknowledging the mistake within your practice can bring about constructive systems changes.

— Rosner F, Berger JT, Kark P, et al. Disclosure and prevention of medical errors. Arch Int Med. 2000;160(14):2089–2092.

Fraud and abuse prevention 101

One way to begin a compliance program in your practice is to conduct educational sessions for your physicians and staff, focusing on areas such as correct coding, billing and documentation. Three months later, conduct an initial baseline audit, and continue with annual audits after that. The audits should involve five to 10 charts per physician and two to five records per payer, as recommended by the Office of Inspector General. Where problems are found, address them within 60 days of discovery.

— The real deal on health care compliance: debunking the myths. AGG Notes. Philadelphia, Pa: Alice G. Gosfield and Associates. 2000;12(1):7.

Signs you're understaffed

Of course, every practice should pay attention to its bottom line, but cutting costs too closely in key areas, such as personnel, may have some unintended consequences. If any of the following sound familiar, it may be time to consider hiring additional staff:

  • Patients and referring physicians complain about being kept on hold for too long when they call your office.

  • Your schedule is unable to accommodate patients within a reasonable time.

  • You're constantly seeing patients behind schedule.

  • Phone messages are going unanswered.

  • Your staff members are treating patients and referring physicians brusquely or downright rudely.

— How to tell if you've cut costs too deeply. The Physician's Advisory. Conshohocken, Pa: Advisory Publications. May 2000:6–7.

Insurer promises better income for better outcomes

More and more health plans across the country are taking measures to incentivize high-quality care. One of the latest efforts comes from the Central Florida Health Care Coalition, which has proposed paying higher fees to physicians who achieve superior clinical outcomes. According to the June 19 American Medical News, the coalition's plan would categorize physicians as platinum, gold or silver based on clinical outcomes for 10 conditions, including diabetes, depression, hypertension and chest pain.

Becky Cherney, president and chief operating officer of the coalition, said that under the plan, reimbursement rates could range from 70 percent of the current Medicare rate for silver physicians to 120 percent for platinum doctors. The plan would also adjust co-payments to drive more patients to top performers.

A recent pilot of 125 physicians has been completed, but no date has been set for implementation. Although the coalition expects doctors to embrace the plan, some Florida-area doctors have already voiced skepticism about linking pay to quality defined by nonphysicians. Others insist that quality cannot be sufficiently measured.

Quote. Endquote.

“This has confirmed my commitment to the Patient Bill of Rights. … If they can kick me around like this, imagine what happens to a guy who has no connections.”

U.S. Rep. John Dingell, D-Mich., commenting in the Aug. 6 Detroit Free Press on a tangle with his HMO following his recent ankle surgery. The Patient Bill of Rights that he sponsored with Rep. Charles Norwood, R-Ga., is still pending in Congress.

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