Tuesday, July 22, 2014

An Insider's Guide to a Health Care Policy White Paper

Do you want to "raise awareness" of how physician quality and value information impacts health care decision making?   Do you want to spin your data via the Associated Press internationally?

Just have the Robert Johnson Wood Foundation pay for a survey!

We all know how great surveys are, especially when you design it to "raise awareness" for the low, low price of $604,454!

For that price, you get:

(1) A nice glossy white paper that contains a concerned patient looking away while she's being examined by a doctor on the cover
(2) Lots and lots of numbers and scientific-looking charts.
(3) An NORC Press release (After all, it was laundered through the Associated Press-NORC Center for Public Policy Research!)
(4) A republishing of your "key points" by a few business-minded online health care journals eager to demonstrate relevance of using "quality measures" to determine health care "value."
(5) An opportunity to collaborate "on all aspects of the study!"

See how easy it is to make sure you get your major points out there to the decision makers!  (Never mind that a quality physician means many different things to many different people - stop being a perfectionist, okay?)

Look, these guys did a survey with 25% response rate that totaled a whopping 1002 people - or about 0.000000317 of the current US population!  Heck, no bias there, right?  Then they add a few "sampling weights" and calculate the survey response rate using the important sounding American Association of Public Opinion Research's Method 3!

What's that?  You're not familiar with Method 3?  What kind of scientist ARE YOU???? 

Here. Let me help:  If Method 1,2, or 4 doesn't get you the desired number, you use Method 3!  The survey response rate for Method 3 is calculated from the handy, dandy Response Rate Method Calculator where:

I = Complete Interviews
R = Refusal and Break Offs
NC = Non-contacts
O = Other
e = the estimated cases of unknown eligibility that are eliglible! (In other words, a guess)
UH = Unknown Household
UO = Unknown Other

Using these definitions , the "Method 3" calculation for the survey response rate becomes:

I / (( I+P) + (R + NC + O) + e(UH + UO))

See? And that response rate, according to the white paper, after applying "sampling weights" had "an overall margin of error" of  "+/- 4.0 percentage points, including the design effect resulting from the complex sample design."

 Heck ya, I'm seeing accuracy there, aren't you?

These days, it's really important that lots of people see these data so policy makers (who have about as much scientific wattage as an LED), can turn to them to create controlling policy and regulations that benefit those who make - you got it - the policy and regulations!  Especially in US health care.  That's because doctors are getting a bit unruly and need to understand why they must fall in line on all this physician quality measurement stuff.  Perhaps one of the introductory paragraphs of the published white paper says it best:
"Major investments are being made in health care systems like Accountable Care Organizations and in tools like Physician Compare. Similarly, health insurers and employers are exploring new benefits designs that incentivize consumers to select providers and hospitals that provide the highest-quality care while reducing costs through value-based provider networks and tiered health plans."
So there you have it!

It's important that we all understand just how critical these surveys paid for by political organizations will be to health care in the years ahead.  Spin, you see, is everything.  Thank goodness the Robert Johnson Wood Foundation (who's CEO, by the way, has also partnered on other publications about patient safety and medical professionalism with members of the American Board of Internal Medicine and National Quality Forum) can show us the way!

I feel so reassured that this is the caliber of science being used to shape US health care now.


What could go wrong?


Sunday, July 13, 2014

The Game of Numbers

The dark underbelly of health care is becoming all too visible now.

Fresh faces in neatly pressed white coats are in the halls.  Eager.  Enthusiastic.  Clearly very bright.  All hoping for a moment, an experience, an encounter that makes all their hard work worth it.  Surely they'll have one, but not before the thousands of keyboard clicks, the mandatory lectures, rounds and lots of lengthy, lonely call nights.

He was a doctor from another time, well into his 80's.  Lovely man with an infectious smile, mesmerizing foreign accent, and almost regal presence. An authority in his time and still attends lectures to stay engaged, a question passed his way from time to time out of respect for his experience and insights.

But he kept nearly falling at night and became concerned; even confused once.  This was not like him.  So he was admitted, observed and had a heart rhythm that was not normal.  Blood thinners were started cautiously.  Surely he could manage them.  His wife, ever-present at his side, was equally engaging, concerned.  And so, as fate would have it, after hundreds of thousands of keyboard clicks, I came to know them and realize his heart beat was too slow at times, dangerously so.

After lengthy discussions of the good and bad, the options, the data, he agreed a pacemaker made sense.  Trustingly, he wanted it performed soon, eager to return to the lectures he loved.  So the next morning after a night of worry, we assembled.  His smile greeted me as I came to his bedside to obtain written consent, answer any last-minute questions, and silence the noise of concern.  He was ready to go.

So I left his bedside to change into my scrubs, trying to hang my newly pressed shirt and tie to the side to preserve it for later behind a changing room curtain, when I heard a voice.

"Dr. Fisher, I'm so sorry..."

"What's up?"

"We can't bring your patient in the room."

"Why not?"

"We didn't know he's UnitedHealthCare.  He's Medicare Part C!"


"You  placed your order after 4PM, and we didn't see it until this morning.  We have to get pre-approval from UnitedHealthCare for his pacemaker.  They said it would be two or three hours..."


"Yes.  It's his insurance.  If you don''t get pre-approval, you won't get paid and he might have to pay for the procedure."

I stood, pants in hand, dumfounded.  So I finished changing and exiting the changing area to clear my head.  I called our administrator.  She said, "Let me see what I can do.  I'll call you right back."  Within minutes a reply was sent: "You have to wait."

I thought of my frightened patient lying there vulnerable, so I went to his bedside to explain.  He looked at me as a fellow physician, and he shook his head in disbelief, all the while naked beneath the covers.  He agreed to wait - he had no choice.  I left to get a cup of coffee and to collect my thoughts.  What else could I do?  I put a detailed note, an order, a consent order last night, and a pre-anesthetic note this morning.  All keyed in, all according to protocol.

Then a nurse appeared with a note.

"If you call this number, hit "3" on the menu selection, and enter this case number, you can do a peer-to-peer."

"A what?"

"Peer-to-peer approval.  You talk to a medical director and they might be able to expedite the approval for the pacemaker."

I looked for a moment at the "800" number, sighed, and called.

The woman who eventually answered after I heard "all attendants are busy" was pleasant enough, full of "good morning, doctor" and "what can I do for you."  I explained the situation and wanted the ordering physician's name.  I spelled my name to her. Keyboards were heard in the background.

"I see that his is for a CPT code 33208, correct?"  She must have known that I knew my codes.  But I knew that was wrong.  He was not getting a dual chamber pacemaker, he just needed a single chamber, VVIR pacemaker.

"No, that's not correct.  It should be 33207," I replied.


I heard more clicking.

"I'm sorry but I've tried to change that code under this case number and it seems I don't have authorization to do that.  Can I put you on hold while I speak with the medical director to see if he can make the change?"

"Sure," I said.  What choice did I have?

So I waited, listening to some nondescript melody in the background as I was placed on hold.  A few minutes later, the same voice returned.



"It seems the medical director couldn't change the information on this case number either, but I'm going to try to make a new number based on the CPT code you gave me, then I'll have the right information to give to the medical director, okay?"

So we proceeded to build a new case number.  Lots of clicks interspersed with silence, then more clicks in the background, a few more statements like, "Sorry, I'm new to this" and "could you spell your name again," then finally:

"There.  I think I've done it.  Let me transfer you to our medical director...."

A click, some music, then a pleasant official-sounding woman's voice.  "This is Doctor Frigamafrats.  I'm sorry about the delay, I hope you didn't have to wait too long..."

A conversation ensued.  I explained the rationale for the pacemaker, then finally was granted approval.  Case number 2342343240 and approval number A321232451, or something like that.  I notified the staff and handed the numbers to our clerk, knowing full well that pre-approval does not guarantee payment.  Forty minutes rather than 120.

It's the game we play now.  A new game.  The Game of Numbers.  Of money.  Clinical doctors as agents for others who call themselves a "doctor" yet are unfamiliar with the patient and unexposed while they make the call.

As I adjusted my headlamp before scrubbing, I thought about those new interns and residents on our wards upstairs, eager, willing, able.  Bustling about, yearning to make a difference, waiting for their first chance...

... yet all being groomed to play the game.


Friday, July 11, 2014

How Much Physician Anti-MOC Sentiment Is There?

This chart says it all:

(Click to enlarge*)

Now that this is firmly established, the question becomes, what are are we going to do about this?  Create legislation altering the Affordable Care Act?  Develop a separate testing authority to compete head to head with the ABIM's process?  Mass non-compliance?  Suit?

This challenge is a good representation of Nancy Pelosi's famous line: "But we have to pass the bill so that you can find out what is in it away from the fog of the controversy."

Well, now that our new health care law has been enacted with the ABMS's MOC program firmly in place, change will not come easily.  This is a great example of how difficult it will be to change any part of our new health care law that is problematic.

I encourage readers to post their suggestions regarding how they might consider changing the ABMS MOC program requirement contained in our new law in the comment section of this blog.


*Reference:  ACC Member Survey

Wednesday, July 09, 2014

Examining Maintenance of Certification Failure Rates

The American Board of Medical Specialties' (ABMS)  Maintenance of Certification® (MOC) program is marketed as "an ongoing process of education and assessment for certified physicians to improve practice performance."  After reviewing the recent failure rates of this program over the past five years, I worry the process is not about assuring physician quality, patient outcomes, or practice improvement, but rather as a means to ration the number of doctors eligible to earn Center for Medicare and Medicaid Services (CMS) payment incentives.


As I've previously reviewed, the ABMS MOC program and the physician registry it creates has been written into our new health care law. To date, the MOC program serves as the sole measure of physician "quality" for the upcoming CMS value-based physician payment model that is to replace the current fee-for-service model in 2015.  To create an incentive for physicians to participate in the MOC program, CMS offered a 0.5% payment incentive to the Physician Quality Reporting System for physicians participating in the MOC program in 2014.  While this does not sound like much money, if we consider that physicians were paid $77 billion from CMS in 2012, this 0.5% represents approximately  $385 million dollars paid to doctors (or their employers).  Imagine the cost savings to the government if physicians were not eligible for such a payment.


I decided to evaluate the failures of "first time" MOC certification for all board certifications issued by the American Board of Internal Medicine from the pass rate data published online by the ABIM.  The number of failing physicians was calculated by subtracting the total number of doctors taking each examination from the number of doctors passing the test to arrive at the number who failed.  Non-integer values were rounded.  Next, I added up the total number of doctors who took the various ABIM MOC examinations each year and the total number who failed each year to generate an annual MOC percentage failure rate.  I calculated these values for 2009, 2010, 2011, 2012, and 2013.  I then applied a linear regression line comparing the total test takers and the total number of doctors failing the examination by year.  I then calculated the number of "certified" physicians each year as a "difference" of the total and failed physicians each year and applied a 2-period moving average trend line to these values.


Here are the raw data assembled in a chart for your review: 

Year 2009 2010 2011 2012 2013
Total Test Takers (n) 8744 9574 10889 11524 12201
Number Failed (n) 861 1030 1357 1610 2138
Percent Failed 9.85% 10.76% 12.86% 13.97% 17.52%
Difference (n) 7883 8544 9532 9914 10063

Plotting these data shows the following trends:

MOC Failure Rate Trends (click to enlarge)


While the number of first-time MOC test takers grew each year studied, the failure rate also grew significantly. Is this because physicians were significantly less intelligent in 2013 than 2009?  Does this mean that board review courses run by each of our professional specialty societies are less relevant now than they were  despite their growing price?  Or might such a failure rate really be a way to "bend the cost curve" for health care delivery by covertly rationing the monies CMS pays physicians?  Each of these are fair questions that need to be answered honestly by CMS, the ABMS, the ABIM, and our professional specialty societies that collude with the ABMS as they run their various MOC board review courses. 

It goes without saying that test scoring methods and the raw responses of questions performed as part of the MOC process are shrouded in secrecy and serve no retrospective educational learning opportunity for doctors taking these examinations.  Doctors who take the MOC testing must also sign a statement that they understand that  divulging content in the examination will be met with harsh penalties including, but not limited to, possible revocation of hospital privileges or reporting to state medical licensing boards.  In return for this promise of secrecy, the ABMS and ABIM appears to operate in an environment that violates the trust of the public and those they test.  They do not explain their consistently higher failure rates seen year over year.  They do not mention the relationship they have to physician payments from government sources when physicians enroll in their MOC program.  Instead, they describe their process as "voluntary."  They espouse  the ethic of  "the need for public accountability and transparency," yet deliver none of these things themselves.  As such, it is clear that physician quality assurance or practice improvement is not the ABMS or ABIM's real mission for public good.

Rather, it appears from the MOC program failure trends above that the real reason for the ABMS MOC program is not only for self-enrichment, but to provide government cost savings without regard to the professional consequences to the many physicians they test and the patients ultimately affected by the loss of eligible care providers from their insurance panels. 


Monday, July 07, 2014

New CMS National Coverage Decision for Pacemakers Begins Today

A new CMS National Coverage Decision for pacemakers begins today.  Here are the specifics.

If your patient is getting a pacemaker for atrial fibrillation or other "ineffective atrial contractions" with symptomatic bradycardia, be very sure to document the "non-reversible" nature of the symptomatic bradycardia in your note and have your billing staff consider adding a "KX" modifier to the claim line(s).

Remember, most regulators look at codes, not notes.

Just sayin' -


Saturday, July 05, 2014

The Effects of Maintenance of Certification and Crony Capitalism

This note was recently posted on Sermo (login required) Friday:
"I just got results from recent ABIM 10 yr recert and I failed. I over prepared for this exam, studied daily for months, Harvard review course, analyzed over 1000 board type questions the week before, teach medical students daily. I have never come close to failing any previous board exams."
After a panicked e-mail was sent to the American Board of Internal Medicine (ABIM) inquiring if there might be an error in the scoring of the examination, this email was received:
Dear Dr. B:

Thank you for your recent e-mail to the American Board of Internal Medicine (ABIM).

ABIM is entirely satisfied that there was no error in scoring your examination. The scoring process is a meticulous one. A rigorous set of quality control steps are carried out on every examination. Before final scores are approved, the reliability, validity, and fairness of the examinations are verified by the ABIM. ABIM will not release results until it is satisfied that a reliable instrument has been administered and data are accurate. Additional information about the way ABIM develops and scores its examinations is at ABIM's website at www.abim.org/about/examInfo/developed.aspx.

If you would like to have your examination rescored, please put your request in writing. All requests must be received within six months of the results' mailing date. Include your name, candidate identification number, the examination to be rescored, and a check for $250.00 payable to the American Board of Internal Medicine. Send to:

Rescore Request
American Board of Internal Medicine
510 Walnut Street, Suite 1700
Philadelphia, PA 19106-3699

Results of the rescore will be mailed to you within eight weeks of receiving your request.

If you need further assistance, you may reply to this e-mail or call us at 1-(800)-441-ABIM (2246) Monday through Friday, 8:30 a.m. to 8:00 p.m., and Saturday, 9:00 a.m. to 12:00 p.m. EST.


Ethan Lambert
Customer Service Representative
American Board of Internal Medicine
510 Walnut Street, Suite 1700
Philadelphia, PA 19106
Phone: 1-800-441-ABIM
Fax: 215-446-3590
This scenario could happen to any US physician undergoing the American Board of Medical Specialties (ABMS) proprietary Maintenance of Certification program today. The hundreds of hours of preparation, survey collection, and timed test, all wasted. And since hospital credentials, legal credibility, and inclusion on insurance panels are increasingly requiring a favorable certification "status," the potential consequences to U.S. physicians are very serious indeed.

This threat to U.S. physicians' ability to practice medicine comes at a time when insured patient populations have swollen. So why would such a "Maintenance of Certification" program be beneficial for American's? Is such a program really about assuring some definition of quality physician? Or might it be about something very different?

While the realities of this situation are sure to raise physician emotions (and maybe the concerns of patients, too), there are several important facts that all physicians and interested patients should understand regarding the American board of Medical Specialties' (ABMS) Maintenance of Certification process that is administered by the American Board of Internal Medicine (ABIM):
  1. The Patient Protection and Affordable Care Act (Affordable Care Act)1 modified sections of Social Security Law2 to require Maintenance of Certification of physicians as a condition of receiving payments from Centers for Medicare and Medicaid Services (CMS).3
  2. While other organizations may create a "qualified Maintenance of Certification program," the only program specifically authorized  in the Affordable Care Act is the Maintenance of Certification program from the American Board of Medical Specialties (ABMS).3
  3. "Qualified Maintenance of Certification" programs must contain surveys as part of their criteria4 despite their lack of scientific rigor.
  4. According to law, the Maintenance of Certification program will be operated by a "specialty body" of the American Board of Medical Specialties" that meets the criteria for a registry or physician quality and efficiency measurement" for physician payment. It is now clear this "specialty body" is the American Board of Internal Medicine (ABIM).3
  5. CMS will receive a portion of $5 million dollars in 2014 from the Federal Hospital Insurance Trust Fund and $15 million from the Federal Supplementary Medical Insurance Trust Fund for the first 6 months of 2015. The National Quality Forum also receives a potion of these funds5
  6. The Administrator of the CMS shall through contracts develop quality and efficiency measures (as determined appropriate by the Administrator) (editor's note: along with "multi-stakeholder group input into selection of quality and efficiency measures")6
  7. The current President and CEO of the American Board of Internal Medicine, Richard J. Baron, MD served as Chair of the ABIM Board of Directors in 2008 and as Treasurer of the Board in 2007 and later as a Trustee for the ABIM Foundation while also serving as the Group Director, Seamless Care Models, at the Innovation Center at CMS.
  8. The former President and CEO of the American Board of Internal Medicine, Christine Cassels, MD, left the ABIM to join the National Quality Forum, another "consensus-based entity," and also had significant conflicts of interest with the group purchasing and performance improvement firm Premier, Inc and Kaiser Foundation Health Plans and Hospitals which she later relinquished. Despite these conflicts, she retains her current position.
  9. An unfinished public webpage (Here's a backup screenshot in case this webpage disappears) raises speculation that current ABIM President and CEO, Richard J. Baron, MD might be slated to sit (or may currently sit) on the National Quality Forum's Board.

Crony capitalism is pervasive in Washington, DC and nowhere is this more evident than the American Board of Medical Specialties and the American Board of Internal Medicine incorporation into our new health care law. The conflicts of interest contained within the Affordable Care Act's requirement of Maintenance of Certification as a basis to assess physician quality are increasingly harmful to physicians.  Given the conflicts of interest between the American Board of Internal Medicine, National Quality Forum, and the Center for Medicare and Medicaid Services, paired with the growing Maintenance of Certification failure rates of physicians without a clear explanation, the specter of cost control at the expense of patient care must be considered.

Only by understanding the environment of government cronyism and regulatory entrapment created by our new health care law can  physicians begin to address these very real concerns for patient care.


 1 Full text of Affordable Care Act: (pdf 2.1 MBytes)  
 2  42 U.S. Code § 1395w–4 - Payment for physicians’ services
 3 ACA law pdf above, page 247 (124 STAT. 365)
 4 ACA law pdf above, page 845 (124 STAT. 963)
 5 42 U.S. Code § 1395aaa - Contract with a consensus-based entity regarding performance measurement
 6 42 U.S. Code § 1395aaa-1 - Quality and efficiency measurement

Wednesday, June 25, 2014

The Quiet

With the advent of social media and seconds-long news cycles, the internet noise grows louder.  Everyone is listening these days: new organizations, stock holders, businesses, special interest groups, and yes, the government.    There are even websites devoted to "secure" areas where the noise can permeate.

The Internet, you see, is it.

Yet what about The Quiet? 

The Quiet is the silent majority.  The Quiet smiles and seems happy.  The Quiet appears unaffected by policy changes and mandates.  The Quiet doesn't mind typing.  The Quiet follows rules. 

At least for a while.  The great cameleon.

So it comes as no surprise to The Quiet that the largest medical device company in the United States recently "purchased" another to avoid some taxes and improve its clout. 

A Quiet move.

And what about the National Quality Forum (here) or the Institute of Medicine's (here)  little conflicts of interest lapses?  And those electronic medical record  or insurance problems?

Shhhh.  Say nothing.  Smile.  No big deal, remember?

Dinner conversations with sons and daughters.  It's different now.  Consulting, enginnering, finance, or maybe nursing. Why be trapped by debt and a dwindling supply of paid residency positions?  There are other ways to help people.  Explore them.  See what you think.  You're young, remember?

The Quiet is marking time, working hard, advising.