reimbursements

Cervical cancer vaccine used by 25 percent of girls 13 to 17

Anne Zieger — Fri, 10 Oct 2008 14:33:55 -0400

Well, I'd certainly call this a marketing success: It appears that one in four girls ages 13 to 17 have received Merck & Co.'s new vaccine against cervical cancer, Gardasil. This comes after a major direct-to-consumer advertising blitz by Merck, as well as lobbying in several states to make the vaccine mandatory.

The vaccine, which comes in a three-shot series, attacks strains of the HPV virus which causes about 70 percent of cervical cancers. The study covered girls from 13 to 17 only. CDC officials, who sponsored the effort, involved responses from about 3,000 girls.

Since health officials recommend that girls get the vaccine when they are 11 or 12, if possible, the percentage of girls within the whole target population who have gotten the vaccine may actually be larger.

Vaccine supporters had actually been hoping for higher vaccination rates, arguing that the shots could cut down on the almost 4,000 cervical cancer deaths that occur each year in the U.S. But there are some factors holding families back from getting their daughters these shots, including safety fears and high cost ($375, which is often but not always reimbursed by health plans).

To learn more about the progress of Gardasil:
- read this item from The New York Times

Related Articles:
Merck stops lobbying for mandated HPV vaccine
Doctors protest low Gardasil reimbursements
FDA staffers raise Gardasil questions
Merck's Gardasil faces critical new hurdle

California MD groups get $65M in P4P bonuses

Thu, 28 Feb 2008 06:59:57 -0500

It looks like some California medical groups and IPAs are profiting from their participation in pay-for-performance programs--but not that much. According to the Integrated Healthcare Association, health plans paid out $65 million in P4P bonuses to medical groups in 2007, up $10 million from the previous year. The bonuses, which were paid out during the third and fourth quarters of 2007, were based on 2006 performance. The program included 235 medical groups representing 40,000 physicians and caring for 12 million health plan enrollees.

While these numbers sound great, the truth is that the bonuses averaged only about 2 percent of annual reimbursements to the participating groups, not enough to make a huge impact on their practice. However, some groups' bonuses were as much as 5 percent of annual reimbursement.

To learn more about the IHA's P4P program:
- read this Sacramento Business Journal article

Related Articles:
MI groups make P4P dollars through IT use. Report
Pay for performance becoming business as usual. Report
CMS program would base hospital pay on performance. Report
Exclusive: How to make P4P work. Interview

Medical practices get the squeeze in '08

Wed, 09 Jan 2008 06:59:58 -0500

If you're a physician-businessperson, it's looking like 2008 is going to be a particularly tricky year to navigate. Not only will physicians face a 10.1 percent Medicare cut, Medicare may also cut reimbursements for ASCs, and state regulators (notably in New Jersey) are questioning ASCs' basis for operating. Even worse, new federal rules that could ban more-profitable physician-owned hospitals loom on the horizon, possibly taking away a financial offset to otherwise crushing financial pressures.

On the expense side, physicians may soon need to use e-prescribing technology if they want to meet all 119 criteria for CMS's Physician Quality Reporting Initiative. Combine that with strong pressure to use electronic medical records, and ongoing pressure to cut in scarce physicians for adequate salaries, and we're talking about some serious investment here.

Perhaps the only clear bright spot for physician business owners, is that medical malpractice costs have fallen for some specialties, including orthopedics, OB/GYN, cardiology, internal medicine and general surgery practices, according to the Medical Group Management Association.

To find out more about these trends:
- read this Modern Physician piece (reg. req.)

Related Articles:
Big medical practices want more pay for IT. Report
Primary care MDs ask patients for extra dollars. Report
Study: Primary care costs, reimbursement low. Report
NJ decision would shut down state's surgery centers. Report

AMA opposes revision of Medicare bill

Mon, 10 Dec 2007 06:59:57 -0500

The American Medical Association recently drafted a letter to the Senate Finance Committee, stating that the Medicare Bill currently under Senate consideration should not reverse a reduction shift the cost of reversal for physician reimbursements to future years. The AMA circulated the letter to other lobbying groups for signatures but did not send it, since Senate Finance Chair Max Baucus (D-MT) "canceled the mark-up of the Medicare bill in favor of direct negotiations with the House Ways and Means Committee." Baucus recently debated this issue with committee Republicans, going back and forth about reversing reductions in Medicare physician reimbursements for one or two years.

In the draft, the AMA urges the Committee not to "rely on 'balloon financing,'" stating that "if the Finance Committee were to propose such an approach, the undersigned organizations would be forced to oppose the proposal."

To find out more:
- read this Kaiser Daily Health Report article

Related articles:
New Medicare bill would stop 10% MD pay cut. Article
Senate may roll back 10 percent Medicare fee cut for MDs. Report
Physicians see expected 10 percent Medicare cut. Report
A different perspective on Medicare cuts. Report
Physician Medicare cut may be eliminated. Report

Stryker, former division settle false claims allegations

Fri, 16 Nov 2007 06:59:54 -0500

Medical technology provider Stryker Corp., along with former outpatient therapy division Physiotherapy Associates, have agreed to pay $16.6 million to settle allegations that they'd submitted false claims to federal healthcare programs. The settlement resulted from whistleblower suits filed by two private citizens, both former Physiotherapy employees, each of whom will receive $3 million from the settlement.

The U.S. Department of Justice had contended that Physiotherapy submitted false claims to Medicare, state Medicaid programs and the Department of Defense's TRICARE plan. It also said that Physiotherapy had retained reimbursements which were improperly paid, rather than refunding them. In addition to paying the fine, Physiotherapy will enter into a corporate integrity agreement with the HHS Office of Inspector General.

Physiotherapy was purchased from Stryker for $150 million in June, by Chicago's Water Street Healthcare Partners.

To learn more about the settlement:
- read this Memphis Business Journal piece

Related Article:
Uncertainty strikes orthopedic device sector. Report

Aetna limits anemia drug payments

Mon, 22 Oct 2007 06:59:55 -0400

Anemia drug sales have taken a beating since Medicare tightened rules to limit when it would pay for them. Now, Aetna has set limits on anemia drug reimbursements too, issuing new rules that follow Medicare's lead. Observers expect other private insurers to establish similar policies in short order.

Earlier this year, Medicare decided that while it would pay for use of drugs like Procrit, Aranesp and Epogen when used to treat certain cancers, it wouldn't pay to use the drugs to prevent anemia. This move upset so many parties that two House of Representatives members introduced a resolution which would force Medicare to rescind its new policy. (The resolution is still under discussion.)

To learn more about Aetna's decision:
- read this Los Angeles Times piece

Related Articles:
Dialysis firms defend anemia drug use along ethnic lines. Report
FDA group recommends anemia drug limits. Report
Anemia drug rebates challenged. Report
Regulators question anemia drugs. Report
New study points to danger of anemia drug. Report

Despite fears, Medicare cuts didn't harm cancer care

Tue, 09 Oct 2007 06:59:57 -0400

When Congress changed the way Medicare paid oncologists in 2003--cutting reimbursements by 30 to 40 percent--critics charged that patients would have less access to care. However, a new study suggests that such fears may have been largely groundless.

The study found that at minimum, patients aren't waiting any longer on average for chemo to begin, and that they aren't traveling any further to be treated than they did in 2003. The study, which surveyed 1,400 men and women with cancer who had Medicare coverage, found that the average wait for chemotherapy following a diagnosis was about three weeks, the same as it had been before 2003.

However, it's worth noting that despite average travel times and waits for care holding steady, there were some problems that came to light. For example, rural patients did see some impact, as they now wait four weeks rather than three for chemo to begin.

To find out more about the study:
- read this article from The Washington Post

Related Articles:
Groups slam CMS prostate cancer policy. Report
US faces major oncologist shortage. Report
Study: Uninsured cancer patients diagnosed later. Report
Study: Childhood cancer survivors lack follow-up. Report
Bill promotes standardized cancer care. Report

ALSO NOTED: Highmark questions cardiac surgery reimbursement report; Indiana examines never events; and much more...

Tue, 04 Sep 2007 06:59:50 -0400

> Health plan Highmark is vigorously questioning a recent report noting large differences in reimbursements for cardiac surgeries in the Pittsburgh area. Article

> A new state report has detailed 85 instances of "never events" and hospital-acquired conditions in Indiana during 2006. Article

> The University of Pennsylvania's hospital has begun offering deluxe patient rooms in its Pavilion section--and charging hundreds more for the privilege. Article

> A new Baylor Health Care System program is helping nurses develop expertise in caring for patients with special needs, including expectant mothers with cardiac programs or neonatal infants with weight loss. Article

And Finally... Can ADD be treated effectively without medications? Some experts think so. Article

AMA fights physician Medicare cuts

Tue, 05 Jun 2007 20:01:38 -0400

The American Medical Association has begun its latest no-holds-barred campaign to make Congress cancel a scheduled Medicare reimbursement cut. As part of its campaign, AMA is publicizing the results of its survey of 9,000 physicians, which found that more than half would to limit the number of Medicare patients they accept if the planned 10 percent cut is implemented. (Sure, there's a bit of grandstanding going on here--but the pain is real, too.) Patients aren't the only ones who would feel the impact. Half of the physicians surveyed would reduce their staff, two-thirds would defer IT investments and 14 percent vowed to "completely get out of patient care," the survey found. Meanwhile, the nonpartisan Medicare Payment Advisory Commission is recommending that Congress avoid reimbursement cuts this year, and argued instead that physicians should get a 1.7 percent increase.

In theory, CMS should have been cutting Medicare payments each year to account for the volume of patients they see, but since 2002, Congress has halted the cuts each year in response to challenges from physicians. If implemented, the cuts would shave reimbursement about 40 percent over the next nine years, despite the likelihood that physician practice costs will increase 20 percent over the same period.

To find out more about the cuts:
- read this Cox Washington Bureau piece
- read the AMA press release on and survey highlights

Related Articles:
CMS to cut provider reimbursements 5.1 percent. Report
AMA addresses Medicare reimbursement cuts. Report

MD groups seek new Medicare rate formula

Sun, 20 May 2007 20:01:36 -0400

The current system Medicare used to gradually bump up reimbursement rates for physicians isn't fair, and should be replaced by one which takes physician practice costs into account, a group of 87 medical organizations told Congress. The group, which includes the American Medical Association, notes that hospitals and nursing homes are paid based on their costs. However, physicians are paid based on a formula known as the sustainable growth rate (SGR), tied to the U.S. economy, which has actually led to payment decreases in recent years. For 2008, in fact, physicians would be hit with a 10 percent cut in reimbursements under the SGR system. If the groups can't convince Congress to immediately repeal the SGR, they want Congress to eliminate it gradually, transitioning to a system under which physicians would get more money each year. The Congressional Budget Office has calculated that if physician payments were to climb as little as 2 percent per year, it would cost the federal government $262 billion over 10 years.

To learn more about the groups' proposals:
- read this Modern Healthcare article (sub.req.)

Related Articles:
Physicians winning reimbursement fights. Report
AMA launching campaign to stave off cuts in reimbursement rates. Report