physician practice options: hyponatremia, march 2011

IN THIS ISSUE

EDITORIAL

3 | HYPONATREMIA STRATEGYRisk Factors and Management of Hyponatremia in Oncology Patients

6 | PATIENT CARECase Example:A 79-Year-Old Woman With Confusion and Hyponatremia

8 | CODING UPDATEStart Preparing Now for Implementation of ICD-10 Codes,Says AAPC Vice President

11 | REIMBURSEMENTHow to Increase Collections While Preserving Patient Relationships

13 | MEDICAL HOMESNCQA’s New PCMH Standards Call for Increased Patient-Centeredness

14| PRACTICE MANAGEMENT NEWSAMGA Employee Satisfaction Database Exceeds10,000 Health Care Employees

In the near future, all health care providers can look forward to some type of newpayment arrangement for their services. CMS is slated to begin establishing account-able care organizations (ACOs) for Medicare patients in 2012. CMS anticipates that

coordination and cooperation among providers will improve quality of care and reduceunnecessary costs.According to CMS, “for each 12-month period, participating ACOs that meet specified

quality performance standards will be eligible to receive a share of any savings if the actu-al per capita expenditures of their assigned Medicare beneficiaries are a sufficient per-centage below their specified benchmark amount.” The benchmark for each ACO will bebased on the most recent available three years of expenditures forMedicare Parts A and Bservices for each beneficiary.Assignment to an ACOwill be invisible toMedicare enrollees, and won’t affect their ben-

Continued on page 2

CONTRIBUTORS

Abdullah K. Salahudeen, MDProfessor of Medicine,Section of NephrologyUniversity of Texas

MD Anderson Cancer CenterHouston

Michael F. Michelis, MDChief of NephrologyLenox Hill HospitalNew York, N.Y.

Payment ReformWill Soon Affect All ProvidersBy Michael Bihari, MD, contributing editor

Page 3

OPTIONSPHYSICIAN PRACTICE

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Visit www.MDOptions.com to view ourdigital edition and for more practice options information

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MARCH 2011

HYPONATREMIA EDITION

Joseph G. Verbalis, MDProfessor of MedicineChief of Endocrinologyand MetabolismDepartment of MedicineGeorgetown University Medical CenterWashington, D.C.

Gourang P. Patel,PharmD, MSc, BCPSClinical Pharmacy SpecialistCritical CareMedical Intensive Care UnitDepartment of PharmacologyDivision of Pulmonaryand Critical Care MedicineDepartment of PharmacyRush University Medical CenterChicago

Arthur Greenberg, MDProfessor of MedicineDivision of NephrologyDepartment of MedicineDuke University Medical CenterDurham, N.C.

Neil Baum, MDUrologistNew Orleans

Lee Newcomer, MD, MHASenior Vice President, OncologyUnitedHealthcareMinneapolis

JohnW. McDanielPresident and CEOPeak Performance Physicians, LLCNew Orleans

Myron Miller, MDProfessor of Endocrinologyand GerontologyDivision of EndocrinologyDivision of Geriatric Medicineand GerontologyJohns Hopkins Bayview MedicalCenterBaltimore

Alpesh N. Amin, MD, MBAProfessor of MedicineExecutive Director, Hospitalist ProgramSchool of MedicineUniversity of California, Irvine

Donald Hillebrand, MDMedical Director, Liver TransplantationScripps Center for Organ and CellTransplantationScripps Center Torey PinesLa Jolla, Calif.

Michael J Cawley, PharmDAssociate Professor of ClinicalPharmacyPhiladelphia College of PharmacyUniversity of the Sciences inPhiladelphia

Denise H. Rhoney,PharmD, FCCM, FDDPAssociate ProfessorEugene Applebaum College ofPharmacy and Health SciencesWayne State UniversityDetroit

Peter R. Kongstvedt, MDPR Kongstvedt, LLCMcLean, Va.

This newsletter is publishedbyPremierHealthcare Resource, Inc.,Morristown,N.J.

©Copyright strictly reserved.This newslettermaynotbe reproduced inwhole or inpartwithout thewrittenpermissionof PremierHealthcare Resource, Inc.The advice andopinions in this publication arenot necessarily thoseof the editor, advisory board, publishingstaff, or the viewsof PremierHealthcare Resource, Inc., but instead are exclusively theopinions of the authors. Readers are urged toseek individual counsel andadvice for their uniqueexperiences.

EditorRevDiCerto845/[email protected]

ArtDirectorMeridith Feldman

PublisherPremierHealthcare Resource, Inc.150Washington St.Morristown, NJ 07960973/682-9003; Fax: 973/[email protected]

EDITORIALEDITORIAL BOARD

efits or choice of providers. Patients maychoose their own health care providers,whether or not the provider belongs to yourACO. The organization remains responsiblefor the costs and quality of service. Most

importantly, all providers in a system mustagree on common goals and communicateeffectively. Without effective health informa-tion technology, ACOs likely won’t be able toconform to cost and quality regulations.UnitedHealthcare, the nation’s largest

health plan, is piloting a new cancer-care pay-ment model that attempts to separate oncol-ogists’ income from drug sales. Participatingphysicians are reimbursed upfront for apatient’s entire cycle of treatment.Massachusetts is debating the next step to

improve care quality while reducing costs. Itsprivate health insurance arena has beenexperimenting with global payments for pri-mary care services. With eight hospitals andphysician groups, the state’s Blue Cross BlueShield plan (BCBSMA) is using an “alterna-tive quality contract” that pays a set monthlyfee per patient, adjusted for health status.After one year, BCBSMA reports that allgroups improved care and came in underbudget. At least twice as many patients in theglobal payment plan than in traditional planshad regular checkups, cancer screenings, andcontrolled diabetes or heart disease.Only time will tell if these methods will

work outside pilot projects. But you shouldbe ready for changes in how you are paid.�

STAFF

Continued from page 1

2 Practice Options/March 2011

More information on physician practicestrategies is available atwww.MDOptions.com

Michael Bihari, MD

Practice Options/March 2011 3

Hyponatremia has been reportedin conjunction with many can-cer types, including both

hematologic and solid tumors (J AmSoc Nephrol. 2009;20:427A; SupportCare Cancer. 2007;15:1341–1347). Theincidence of hyponatremia in cancerpatients is unclear, as reports evaluatevarying populations and use differentdefinitions of hyponatrem-ia (Table 1, page 4). Agroup of researchers fromtheUniversity of TexasMDAnderson Cancer Centerin Houston has examinedcharacteristics and effect ofhyponatremia in theirpopulation. Their prelimi-nary findings indicate thathyponatremia (serumsodium <135mmol/L) wasdetected on admission innearly half (46%) of 2,960patients hospitalized atMD Anderson during four months in2006 (J Am SocNephrol. 2009;20:427A).“The incidence is much higher than

people might suspect,” said AbdullahK. Salahudeen, MD, professor of medi-cine, Section of Nephrology at MDAnderson and coauthor of the abstractsummarizing the group’sfindings.

Causes of HyponatremiaPatients with cancer have multiple riskfactors for hyponatremia. Syndrome of

inappropriate antidiuretic hormonesecretion (SIADH) is a common etiolo-gy of hyponatremia in cancer patients

(Emerg Med Clin N Am. 2009;27:257–269). Tumor cells may produceantidiuretic hormone (ADH), alsocalled arginine vasopressin (AVP),even in the presence of serum hypo-tonicity (Emerg Med Clin N Am.2009;27:257–269). Small-cell lung can-cer in particular has been associatedwith this complication (Emerg MedClin N Am. 2009;27:257–269; J ClinOncol. 1986;4(8):1191–1198). “Thepatient hoards water, thus diluting theserum sodium,” said Salahudeen.Manychemotherapeutic agents also lead toAVP production or produce hypona-tremia by other mechanisms (Table 2,page 5; Support Care Cancer.2007;15:1341–1347). Cyclophosph-amide can potentiate the effect of AVPas well as increase its release (Am JKidney Dis. 2008;52:144–153).Methotrexate is thought to adverselyaffect the neurosecretory areas of thecerebrum and alter body fluid distribu-tion volumes (Am J Kidney Dis.2008;52:144–153).

Association WithChemotherapyThe nausea and vomiting associatedwith chemotherapy also promote AVPrelease, as does radiation to theabdomen. Pain has been associatedwith hyponatremia, as have the mor-phine and carbamazepine often used totreat cancer pain. Immunomodulatorsand monoclonal antibody therapies

used in cancer care also havebeen associated withhyponatremia (Support CareCancer. 2007;15:1341–1347;Am J Kidney Dis.2008;52:144–153). Cisplatinis postulated to inducehyponatremia through renalsalt wasting (Am J KidneyDis. 2008;52:144–153).The hydration adminis-

tered with cisplatin toprevent nephrotoxicity andother adverse effects of thisagent also can promote

hyponatremia (Support CareCancer. 2007;15:1341–1347). Patients

HYPONATREMIA STRATEGY

Risk Factors and Management ofHyponatremia in Oncology Patients

Continued on page 4

“Most of us are reluctant to discharge apatient with hyponatremia, especiallyin the presence of symptoms, until wehave a correction.…We would prefer tohave the serum sodium close to normal.

That’s why it’s called normal.”—Abdullah K. Salahudeen, MD, Section of Nephrology,

University of Texas MD Anderson Cancer Center, Houston

HYPONATREMIA STRATEGY

receiving many types of chemotherapyoften are instructed to increase theirfluid intake, said Salahudeen. Manypeople respond by drinking largequantities of water. “Water in a patientwith a tendency to retain water is prob-lematic,” he noted. “You are adding fuelto the fire, increasing the risk or sever-ity of hyponatremia.”

Fluid IntakeBecause so many patientswith cancer have risk fac-tors for water retention orother mechanisms ofhyponatremia, Salahudeenadvises patients to drinkfluids that contain solutesrather than only water.Beverages with added elec-trolytes, juices, and decaf-feinated coffee or tea offersafer fluid options. He suggests con-suming caffeinated beverages in mod-eration. “Solute will allow for someremoval of water from the body,” heexplained. This is the mechanismbehind the “archaic” use of urea to treathyponatremia, he said. Consumptionof a low-solute diet also is a risk factor

for hyponatremia in cancer patients.

AssessmentEvaluation of hyponatremia in oncolo-gy patients follows the same principlesas in other populations, Salahudeensaid. The first step is to determinewhether hyponatremia is acute (<48hours) or chronic in duration. Acute

hyponatremia is a medical emergencythat requires treatment, usually withhypertonic saline, he said (Support CareCancer. 2007;15:1341–1347). In cancerpatients seen at MD Anderson, arecord of serum sodium levels often isavailable so the duration of hypona-tremia can be assessed. Most cases of

hyponatremia are chronic as opposedto acute in onset, Salahudeen said.The next step is to assess osmolality

and volume status. Effective osmolalityof less than 275 mOsm/kg H2O is con-sistent with a diagnosis of hypotonichyponatremia (N Engl J Med. 2007;356:2064–2072). If volume status isunclear or requires confirmation,

administration of isotonicsaline can alleviate or ruleout hypovolemia (Am JMed. 2007;120[11A]:S1–S21).

ManagementPatients with visible edemawho are judged to be hyper-volemic can be treatedwith diuretics or the vaso-pressin receptor antago-nists, Salahudeen said.

Euvolemic patients might be treatedwith fluid restriction to less than 600 or1,000 mL daily.Salt tablets offer another option for

those patients who can tolerate them.Possible adverse effects of this therapyinclude edema and aggravation of anypre-existing hypertension, Salahudeen



TABLE 1. RATE OF HYPONATREMIA IN CANCER PATIENTS

Many patients respond by drinkinglarge quantities of water. “Water in apatient with a tendency to retain wateris problematic. You are adding fuel tothe fire, increasing the risk or severityof hyponatremia,” Salahudeen said.

Study

Lung Cancer.2010;68[1]:111–114

Pediatr Blood Cancer.2010;54[5]:734–737

J Am Soc Nephrol.2009;20:427A

Br J Cancer.1993;68:767–774

J Clin Oncol.1986;4(8):1191–1198

Subjects

453 patients treated for SCLC at asingle hospital over 10 years

63 children admitted to a singlehospital for chemotherapy or SCT

2,960 patients admitted to a cancerhospital over four months

110 evaluable patients with NHL

350 patients with SCLC

Definition of hyponatremia

Serum sodium ≤135 mmol/L

N/A; mean serum sodium128 mmol/L; range, 120-130

Serum sodium <135 mmol/L

Serum sodium <137 mmol/L

Serum sodium <130 mmol/Lattributed to SIADH

Rate of hyponatremia

44% total; 33%, 126-135mmol/L, 11%, <125 mmol/L

63.5%

46.3%

32%

11%

NHL: non-Hodgkins lymphoma; SCLC: small-cell lung cancer; SCT: stem cell transplantation; SIADH: syndrome of inappropriateantidiuretic hormone secretion

said. Salt tablets may exacerbate nau-sea, vomiting, and other gastrointesti-nal symptoms common amongpatients receiving chemotherapy. Thevasopressin receptor antagonists offeranother option in some euvolemichyponatremic patients (Am J Med.2007;120[11A]:S1–S21).Whether and how to treat hypona-

tremia depends on whether thehyponatremia is of acute or chroniconset, the serum sodium level and itsstability, and whether symptoms ofhyponatremia are present. Symptomsof chronic hyponatremia may includeheadaches or confusion, as well asattention and gait deficits (Am J Med.2006;119[1]:71.e1–71.e8), he said.“Most of us are reluctant to discharge

a patient with hyponatremia, especiallyin the presence of symptoms, until wehave a correction,” Salahudeen said.

Asymptomatic patients with serumsodium of at least 130 mmol/L that isstablemight receive nonpharmacologicinterventions only, he said. The goal oftreatment is symptom improvementand raising the serum sodium toroughly 135mmol/L. “Wewould prefer

to have the serum sodium close to nor-mal. That’s why it’s called normal,” hesaid.�Dr. Salahudeen received no renumeration forthe interview and preparation of this article.—Reported and written by EileenMcCaffrey, in Whippany, N.J.


Hyponatremia attributed to malignancy often resolves witheffective anticancer therapy (Am J Med. 2007;120[11A]:S1–S21). It may recur with tumor progression, how-

ever. Hyponatremia can lead to delay of nonemergency surgery,noted Abdullah K. Salahudeen, MD, professor of medicine,Section of Nephrology at the University of Texas MD AndersonCancer Center in Houston. All high-risk patients at MD Andersonmust undergo a thorough medical evaluation prior to nonemer-gency surgery, he said. If the serum sodium is less than 130mmol/L, a nephrology consult will likely be requested to addressthe issue. Surgery will likely be postponed if serum sodium is lessthan 125 mmol/L.If serum sodium is a “borderline” 130 to 135 mmol/L, the sur-

geon or oncologist might look for “simple” interventions such assubstituting isotonic for hypotonic fluid, Salahudeen said.Hypotonic fluid has been associated with hyponatremia in chil-dren receiving cancer chemotherapy or stem cell transplantation(Pediatr Blood Cancer. 2010;54[5]:734–737). Chemotherapy isless likely than surgery to be delayed due to hyponatremia, butnephrologists are often consulted if hyponatremia develops dur-ing treatment.Hyponatremia has been associated with mortality in general

populations of hospitalized patients. No causal link has beendemonstrated, however (Am J Med. 2009;122[9]:857–865; Arch

Intern Med. 2010;170[3]:294–302). Reports about the impact ofhyponatremia on prognosis in cancer patients are limited andinconsistent.A review of data from 453 patients treated for small-cell lung cancer (SCLC) at a single hospital found that median sur-vival was significantly shorter among those with hyponatremia(≤135 mmol/L; 7.1 months vs 11.2 months, respectively; P =0.0001; Lung Cancer. 2010;68[1]:111–114). Analysis of datafrom 163 patients with extensive SCLC found that serum sodiumdid not significantly affect survival (J Cancer Res Clin Oncol.2007;133[8]:519–524).A study of 110 patients with non-Hodgkin’s lymphoma report-

ed that hyponatremia (defined as serum sodium <137 mmol/L)was significantly associated with not achieving complete remis-sion, shorter duration of remission, and poorer survival (Br JCancer. 1993;68:767–774). Rate of death was higher amonghyponatremic patients than in the overall population of cancerpatients in a specialized oncology hospital (19% vs 6.3%, respec-tively), though no death was attributed directly to hyponatremia(Support Care Cancer. 1999;8[3]:192–197). A preliminary reportfrom the MD Anderson study indicated that hyponatremia wasassociated with higher risk of in-hospital mortality (22% vs 12%;odds ratio, 2.02; 95% confidence interval 1.3–3.2; P = 0.002; JAm Soc Nephrol. 2009;20:427A).

—EAM

THE IMPACT OF HYPONATREMIA ON THECARE AND PROGNOSIS OF ONCOLOGY PATIENTS

Carbamazepine

Carboplatin

Cisplatin

Cyclophosphamide (IV)

Ifosfamide

Interferon α and γ

Interleukin 2

Levamisole

Melphalan

Methotrexate

Monoclonal antibodies

Opiates (eg, morphine)

Pentostatin

Vinblastine

Vincristine

TABLE 2. MEDICATIONS USED IN CANCERCARE ASSOCIATED WITH HYPONATREMIA

Source: Am J Kidney Dis. 2008;52:144–153

Michael F. Michelis, MD, chiefof nephrology at Lenox HillHospital in New York, N.Y.,

described the following case.A 79-year-old woman presented

with a complaint of progressive confu-sion, for which she was hospitalized.Her other recent complaints includedpoorly controlled blood pressure, diffi-culties with concentration andwalking,and unsteady gait. Her medical historywas significant for depression, hyper-tension, hypercholesterolemia, andosteoarthritis. Current medicationsincluded a selective serotonin reuptakeinhibitor (SSRI), enalapril, hydro-chlorothiazide, a statin, and occasionaluse of nonsteroidal anti-inflammatorymedications. Her recent history ofpoorly controlled blood pressure ledclinicians to question her adherence tothe antihypertensive medication. Shelived alone, receiving assistance from apart-time home health aide.Upon evaluation, the patient was

pleasant but slow to respond to ques-tions and directions. Blood pressure,pulse, respiration, and temperaturewere normal. Physical examinationrevealed no evidence of hypervolemia.Initial neurologic examination revealedsymmetrical reflexes and deficienciesin attention span, including a low scoreon an informal Mini-Mental Stateexam. Gait capacity was not evaluated.

Laboratory FindingsA complete blood count (CBC),metabolic panel, and urine studieswere ordered and yielded the followingfindings:• CBC unremarkable; no anemia• Serum sodium, 119 mmol/L• Serum potassium, 3.8 mmol/L• Serum uric acid, 3.9 mg/dL• Blood urea nitrogen (BUN), 10mg/dL• Serum creatinine, 0.7 mg/dL• Urine sodium, 43 mmol/L

• Urine potassium, 18 mmol/L• Urine osmolality, 424mOsm/kg H2O• Plasma osmolality, 251 mOsm/kgH2OThe patient’s effective osmolality of

247 mOsm/kg H2O (plasma osmolali-ty minus BUN/2.8) ruled out consider-ation of pseudohyponatremia (N Engl JMed. 2007;356:2064–2072). Based onclinical appearance, the patient wasdiagnosed with symptomatic euvol-emic hypo-osmolar hyponatremia.

Days One and TwoUpon admission, the nephrologistordered fluid restriction and stoppedthe hydrochlorothiazide. Thiazidediuretics have been associated with riskof hyponatremia, especially in elderlywomen (Am J Kidney Dis. 2008;52:144–153; Am J Med. 2007;120[11A]:S1–S21). Thiazide-induced hypona-tremia is thought to stem in part fromimpairment of urinary dilution with-out effect on urinary concentration(Am J Med. 2007;120[11A]:S1–S21).The patient’s blood pressure was nor-

mal, supporting the safety of stoppingthe antihypertensive medication.Later in the day, a trial of normal

saline (0.9%, given over 12 hours) wasinitiated in an attempt to rule out hypo-volemic hyponatremia and sodiumdepletion. This procedure is generallysafe if urine osmolality is below 500mOsm/kg H2O, as in this patient (NEngl J Med. 2007;356:2064–2072).Restriction of other fluids continued.Clinical and laboratory evaluation

the next morning revealed no changein physical examination, mental status,mobility, or serum sodium (118mmol/L). Repeated measurement ofserum sodium later in the day, toaccount for the effect of the normalsaline trial, showed a relativelyminimalresponse (120 mmol/L).Given these findings, the SSRI was

discontinued despite the patient’s pri-mary care physician’s concern aboutexacerbating her prior severe depres-sion. SSRIs have been implicated incausing hyponatremia by leading tosyndrome of inappropriate antidiuretic


PATIENT CARE

Case Example: A 79-Year-OldWomanWith Confusion and Hyponatremia

CHANGES IN SERUM SODIUM


hormone (SIADH) release. Older ageand concomitant use of a thiazidediuretic are the most important riskfactors for development of SSRI-associ-ated hyponatremia (Am J Kidney Dis.2008;52:144–153; Am J Med Sci.2004;327[2]:109–111). Fluid restrictioncontinued.

Day ThreeThe patient’s mobility and mentalsymptoms remained unchanged as ofthe next morning. Serum sodium was122 mmol/L, despite continuedattempts at fluid restriction. Thepatient was not in a monitored area ofthe hospital, which complicatedenforcement of fluid restriction.A complete neurologic examination

was performed, revealing evidence of alow-grade, relatively small, chronicsubdural hematoma. The hematomawas thought to result from old traumaand the consulting neurologist decidedagainst surgical intervention. Chronicsubdural hematoma of unknown causecan be seen in the elderly, saidMichelis.Reported frequency for adults 70 to 79years old is 7.35 cases/100,000 individ-uals (http://emedicine.medscape.com/article/1137207-overview). Thehematoma was not viewed as a likelymajor contributor to the either patient’ssymptoms or the hyponatremia.Use of tolvaptan was considered but

the agent was not immediately avail-able. Demeclocycline 300 mg threetimes daily therefore was begun.

Days Four Through SevenOn day five, serum sodium was mea-sured at 124 mmol/L. Mental andmobility symptoms persisted, essential-ly unaffected. The nephrologistobtained access to tolvaptan, and theagent was initiated at a dose of 15mg/day on the morning of hospital daysix. Demeclocycline and fluid restric-tion were discontinued. Serum sodiumwas monitored every eight hours. After24 hours of tolvaptan therapy, serumsodium measured 130 mmol/L. After48 hours of tolvaptan therapy (hospitalday seven), serum sodium had risen to135 mmol/L. The patient’s mental acu-ity, reactivity, and responses to ques-tioning had improved substantially, ashad her ability to walk and her gait.Tolvaptan was discontinued and thepatient was discharged. Neither theSSRI nor the hydrochlorothiazide ther-apy was resumed. The nephrologistrecommended that her blood pressureand mental status, along with herserum sodium, be monitored.

CommentaryMultiple factors likely contributed tothe symptomatic hyponatremiaobserved in this patient, Michelis

explained. The nephrologist in turnimplemented multiple interventionssequentially: stopping the diuretic andstarting fluid restriction, initiating atrial of normal saline, stopping theSSRI, giving demeclocycline for twodays, then stopping fluid restriction andswitching to tolvaptan. Fluid restrictionwas difficult to enforce given that thepatient was not in a monitored area. Inaddition, the patient found the fluidrestriction uncomfortable, he said.This patient had risk factors for

hypovolemia and salt depletion.Hydrochlorothiazide can induce soluteloss (Am J Kidney Dis. 2008;52:144–153). Older patients with poormental acuity, living alone and feelingill, may not eat well, Michelis noted.Low solute intake can contribute tohyponatremia (Clin J Am Soc Nephrol.2008;3:1175–1184). Saline replacementtherapy had little effect on the serumsodium in this case, however.The patient’s laboratory values sug-

gest the diagnosis of SIADH. Urinesodium greater than 40 mmol/L withnormal dietary salt intake, inadequatedilution of the urine, and serum uricacid less than 4.0 mg/dL, BUN of lessthan 10 mg/dL are consistent with adiagnosis of SIADH (N Engl J Med.2007;356:2064–2072).�—Reported and written by Eileen A.McCaffrey, in Whippany, N.J.

Renal Week, the American Society of Nephrology annualscientific meeting, was held from November 16–21 inDenver, Co.

Mild Hyponatremia and Fracture Risk:The Rotterdam StudyAnalysis of data from the prospective, population-basedRotterdam Study found that mild hyponatremia (serum sodium<136 mmol/L; mean 133.4 ± 2.0 mmol/L) in older adults (n =5,208, >55 years) was associated with increased risk of vertebralfractures, incident nonvertebral fractures, and mortality.Hyponatremia was not associated with bone mineral density. Riskof vertebral fractures remained significant after adjustment for all

covariates (odds ratio 1.61; 95% confidence interval 1.00–2.59;P = 0.049). Risk of incident nonvertebral fractures (HR=1.39;95% CI 1.11-1.73; P =0.004) remained significant after adjust-ment for age, sex and body mass index. Mean follow-up periodfor vertebral fractures was 6.4 years; for incident nonvertebralfractures, 7.4 years. Risk of all-cause mortality was higher in sub-jects with hyponatremia (HR=1.21; 95% CI 1.03-1.43; P=0.022).Subjects with hyponatremia had more recent falls (23.8% vs16.4%; P<0.001) but the increased fracture risk seen in hypona-tremia was independent of recent falls.Source: “Mild Hyponatremia as a Risk Factor for Fractures: The

Rotterdam Study,” Hoorn EJ, Zietse R, Carola Zillikens M. J AmSoc Nephrol. 2010;21:F-FC232. —EAM

STUDY PRESENTED AT RENAL WEEK 2010

Effective October 1, 2013, theInternational Classification ofDiseases-9 (ICD-9) code sets cur-

rently being used by medical codersand billers to report health care diag-noses and procedures will be replacedwith ICD-10 codes. While the ICD-9system containsmore than 17,000 indi-vidual codes, ICD-10, between theICD-10-CM (Clinical Modification)and ICD-10-PCS (Procedural CodingSystem, for use with inpatient proce-dures) sets, the number of codes willexpand to more than 140,000. ICD-10-CM, which is most relevant to mostprivate physician practices and prima-ry care physicians, will comprise morethan 69,000 of these codes. Coding willrequire a greater degree of specificityand detail under ICD-10, demandingimproved note-taking by physiciansand staff, and greatly altering the waythat medical practices record patientencounters and interact with providersand insurers.

Broad ChangesBecause the changes that go into effectin 2013 will be so broad, organizationssuch as the American Academy ofProfessional Coders (AAPC) and theCenters for Medicaid & MedicareServices (CMS) recommend that allhealth care professionals who will beaffected by them begin preparingimmediately in order to make the tran-sition. Fortunately, there are a numberof good resources available to helpcoders and other professionals. “Wewant to make sure everybody knowsthat this is a large change and take itstrategically and step-by-step,” saysRhonda Buckholtz, CPC, CPMA,CPC-I, vice president of Business andMember Development for AAPC.“That way they’ll be able to adequately

implement ICD-10 with much less costand headache.”The transition to ICD-10 will affect

every function performed in a medicalpractice, Buckholtz says. “Themanagerwill be affected tremendously,” she says.“Any policy or procedure in the prac-tice that is currently tied to a diagnosticcode or a disease management process,or to Physician Quality ReportingSystem (PQRS) or payer quality reportsor any other initiatives, will have to bechanged. Managers will need to under-stand how to get paid under ICD-10,and will have to renegotiate vendorcontracts accordingly. Practices willhave to put somemoney away, not onlyso the practice will be able to make thenecessary changes for the transition,but also to have reserves to tap in casesomething happens and the practiceisn’t getting paid for a period of time.Plus, everybody in the practice willneed some type of training, the frontdesk through the entire staff.”Clinically, ICD-10 will cause exten-

sive changes to patients’ coverage,Buckholtz says. “Every single healthplan, local or national coverage deter-mination, or any other payer policieswill be revised,” she says. “That meanshow practices operate internally willhave to change. How practices pre-cer-tify patients or do prior authorizationscould possibly change to fit ICD-10’smedical necessity requirements. Rightnow we know health plans are chang-ing policies and writing them in thebackground of ICD-10. Plus, ICD-10coding needs to be budget-neutral.Even though there will be 69,000 diag-nosis codes, not all of them will bepayable.”Practices will have to revise their

super bills, or eliminate paper superbills altogether, Buckholtz says, since

the increased number of diagnosticcodes will make it impossible to listevery code on the bill. “Now you’ll haveto add some sort of reporting featurewhere they can spell out a patient’sdiagnosis,” she says. “We’re going tohave to use our words.“In the physician’s office, it’s going to

become necessary to use real worldnotes,” she continues. “Probably 40% to45% of the time, physicians won’t beable to assign an ICD-10 code based onthe clinician’s current documentationprocess. The level of specificity willchange a lot. Physicians will need to beable to document laterality or stages offeeling, weeks of pregnancy, stages ofthe episodes of care. Laterality seemslike a no-brainer for physicians, butonce they leave the surgical suite orexam room and are in their offices,they tend to be much more lax on theirdocumentation. Sometimes they forgetto document whether something hap-pens on the right side or the left side.”

Learning in StagesBuckholtz stresses the importance ofmedical professionals involved in any


CODING UPDATE

Start Preparing Now for Implementation ofICD-10 Codes, Says AAPCVice President

Rhonda BuckholtzCPC, CPMA, CPC-I


aspect of coding beginning to preparefor ICD-10 implementation immedi-ately, because the changes are so broadand sweeping. However, she does notadvise learning any actual codes at thistime. “It’s too soon for coders to startlearning the new code sets becausewe’re currently in an unstable learningenvironment,” she says.“The codes are all in draftformat. Just between2009 and 2010 there wereseveral thousandchanges. Everything isgoing to change. Codersneed to wait for a stablelearning environment.Besides, if they learn thecodes now, since theywon’t be using them, they’ll neverretain them.”

New ResourcesCMS has recently announced a freezeto the code sets, Buckholtz says. “Thatmeans when the book comes out forOctober 1, 2011, which will be the 2012codes, the codes will be frozen,” shesays. “They will be completely frozenuntil 2014, only updating for urgent sit-uations, giving the coders a stablelearning environment.”

AAPC has created a number of toolsand other resources to help coders andother professionals get up to speed onICD-10, Buckholtz says. Much of thisinformation is available through theAAPC Web site (www.aapc.com). “Wehave all sorts of information, includingthree free webinars for providers that

go over the 16 steps for implementa-tion,” she says. “There are also two freewebinars for payers.”The webinars are approved for con-

tinuing medical education (CME)credit. “This is a physician licensingyear,” Buckholtz says. “Physicians canget their last-minute CME credits whilegetting ready for ICD-10 implementa-tion.”The CME webinars are available

now, Buckholtz says. “We don’t advisethat anyone take code training early,

but we’ve opened the door a crack forthose people who feel they just have tobe trained in the code sets once the sta-ble learning environment is there,” shesays.A benchmark tracker on the site

walks the user through the 16 steps ofimplementation. The interactive fea-

ture has a “stoplight”feature that indicates bya red, yellow, or greenlight whether a practiceor professional is up-to-date on a given step inthe implementationprocess. There are alsodistance learning pro-grams for health plans.Another useful tool

on the AAPC site is an online transla-tor. Coders can enter an ICD-9 codeinto the translator and will see whatthat codemight become under ICD-10.“It’s an attempt to crosswalk from ICD-9 to ICD-10, and it can go backwardsfrom ICD-10 to ICD-9 as well,”Buckholtz says. “If coders run a prac-tice management report now of theirmost frequently used ICD-9 codes,they can see what the code selectionwill look like in ICD-10. Keep in mindthat these files can’t code. The forward

ICD-10 IMPLEMENTATION WILL BE DEMANDING ON BILLING STAFF

In implementing the new International Classification ofDisease-10 (ICD-10) codes in October of 2013, every part of amedical practice will be affected, says Rhonda Buckholtz, CPC,

CPMA, CPC-I, the American Academy of Professional Coders(AAPC) vice president of Business and Member Development. Thechanges will be drastic in practices’ billing offices in particular,she says.“All the payers’ policies and procedures will have to be revised

to fit ICD-10’s new medical necessity requirements and billingrequirements,” Buckholtz says. “For every category of code, thereis an unspecified code that coders can pick. I warn all physiciansthat ICD-10 has to be budget-neutral. A lot of payers are indi-cating that they need to refine their policies so they’re not pay-ing for more under ICD-10 than they did under ICD-9.

“The first thing to go will be those unspecified codes,” shecontinues. “If a physician can’t document or tell the differencebetween left side and right side, unless it’s an urgent or emergentsituation, the payers won’t pay for it.“Billers will have to be trained on the new policies and proce-

dures and the ICD-10 code sets,” Buckholtz says. “With the newlevel of specificity that will be required, if you have a coder who’snot strong in anatomy and terminology, now is the time to pre-pare them for the transition and beef up that part of their edu-cation. It’s too soon now to learn the code sets, but they canbegin to make sure they have a strong foundation. That level ofspecificity is going to mean a greater requirement for coders tohave a good understanding of anatomy and the terminologybehind it.” —RD

Continued on page 10

“For this transition to work, it will requireus reaching outside our practices and

working side-by-side with others that we’renot normally used to working with,” saysRhonda Buckholtz, CPC, CPMA, of AAPC.

mapping from I-9 to I-10 will take youto the unspecified code selectionalmost every time. It couldgive you five possible codes,or it could give you 200. Wecaution providers from try-ing to use it as an actual wayto assist them in-depth withcoding, because it can’t dothat. But it’s a good tool tohelp you see what code setsyou may be using frequent-ly.”

Caution NeededBuckholtz is quick to stressthat ICD-10 will require ahigher level of diligence from all mem-bers of a practice. “Nurses will have towatch their documentation to makesure they help the physicians meet thehigher level of specificity,” she says.“Changes to prior authorization or pre-certification are going to require addi-tional training as well.”The ordering of lab tests is an area

that Buckholtz sees as a potential prob-lem for physicians and lab techniciansalike. “One of the problems that lab andradiology both have right now is thatphysicians don’t given them enoughinformation in ICD-9 for them to ordertests and make sure they’re paid for,”she says. “I see that still being a hugeproblem in ICD-10 because they’llneed a higher level of specificity or

more documentation. There will haveto be a lot of collaboration between the

labs and the physician offices to makethe transition work. It’s going to slow alot of work down.”Effective transition will require

health care professionals across theboard to work together, Buckholtz says.

“In order for this transition to work, itwill require us reaching outside our

practices and working side-by-side with others thatwe’re not normally used toworking with,” she says.“Otherwise the physicianwill be completely bom-bardedwith phone calls andrequests for additional doc-umentation.”However, Buckholtz

points out, with theresources available throughAAPC and CMS, alongwith other sources, there isample time for all health

care professionals to get up to speed onICD-10. With enough preparation, thedifficult transition can be made man-ageable.�—Reported by Joseph Burns. Written byEditor Rev DiCerto

CODING UPDATE


Though the transition from International Classification ofDiseases-9 (ICD-9) codes to ICD-10 codes will not takeplace until October of 2013, the broad and sweeping nature

of the changes will require a great deal of preparation on thepart of all medical professionals who are likely to be affected. TheAmerican Academy of Professional Coders (AAPC;www.aapc.com) offers the following online resources to helpcoders, payers, and other professionals prepare:• Introduction webinars• Code set training• ICD-10 connect

• ICD-10 overview, naming conventions, links, news and articles,discussion, and books

• Provider training timeline• Benchmark tracker• ICD-10 code translator (ICD-9 to ICD-10)• On-site, boot camp, and distance learning training for providersand health plansAdditional information on the transition from ICD-9 to ICD-10

coding can be accessed through the Web site of the Centers forMedicaid & Medicare Services (CMS), www.cms.gov.

—RD

ONLINE RESOURCES FOR ICD-10 IMPLEMENTATION


“Managers will need to understandhow to get paid under ICD-10, andwill have to renegotiate vendor

contracts accordingly. Plus, everybodyin the practice will need some type oftraining, the front desk through the

entire staff.”—Rhonda Buckholtz, CPC, CPMA, of AAPC


In recent years, depressing descrip-tors of our economy such as layoffs,wage freezes, foreclosures, and

depreciating investments have becomecommonplace in our language andcontinue to damage the consumer psy-che. Many patients are worried abouthaving enough money from one day tothe next to pay for basics like food andmortgages. As a result, any obligationsthat can be are being pushed aside withgrowing frequency. That includespatients’ health care debts.

In this volatile environment, medicalpractice staff members who collectmoney at the beginning and end of ser-vice have their work cut out for them.Securing patient-pay receivables is get-ting more difficult by the day.With bad debt currently at around 7%to 10% and expected to increase, suc-cessful collection of these receivableshas never been more important to amedical practice’s bottom line than it isright now. For many practices, thosepatient-pay dollars could mean the dif-ference between bottom-line profit andloss.Given the importance of managing

receivables, many practice managersneed to ask themselves why they con-tinue to rely on marginally effectivecollection strategies to recoup whattheir practices are owed. Whether apractice is using internal resources oroutsourcing, does it have methods inplace that might result in resentment,passive aggression, avoidance, and neg-ative patient relations? Is the office staffbanging its head against a wall usingtechniques that fail to motivate pay-ment? There are strategies available topractice managers that can help themachieve their practices’ ultimate objec-tives of collecting a significant percent-age of outstanding revenue, preservingpositive relationships with patients,and casting the practice in the best pos-sible light.

Changing AttitudesPatients don’t pay outstanding debts fortwo reasons: they either believe thatthey can’t pay them or that they don’towe them. However, research fromKeyBridge Medical RevenueManagement shows that 98% ofpatients with outstanding obligationsbelieve that they owe the money.Nearly 40% of patients with obligationsbelieve they can pay them. That meansthat nearly 60% believe they can’t.

While the office staff can’t changethis situation, the collection team canhelp patients change the way they viewthe situation, which can greatly reducetheir resistance to satisfying their debt.Several patient-friendly steps can helpa practice’s staff to accomplish thisobjective.Good patient relations are crucial to

effective collections. Developing a sys-tem where patient rapport is quicklyestablished at the point of service willmake it easier to collect deductibles andco-pays. For both in-person and phonecollection efforts, use a script with care-fully chosen language that won’t invokea “fight-or-flight” reaction in thepatient. For example, when a patient atthe point of service says, “Just send mea bill,” don’t allow staff to simply say,“Okay” and fail to collect the co-pay.Instead, have your staff respond, “Iknow you’d rather have us send you abill. Everyone would. But I also knowyou probably hate getting stacks of billsin the mail. Wouldn’t you like to avoidthat and take care of this now?”Remember that while nearly all

patients accept and acknowledge thatthey owe the debt and many are ableand willing to pay, many are afraid thatthey can’t. Build a response throughlanguage that promotes empathy,builds rapport and trust, and motivatespatients to pay.Finally, educate the patients. Make

sure they understand their paymentoptions, and work with them toward asuccessful resolution.

Enlisting StaffA crucial component of any bad debtreduction program is the buy-in of apractice’s patient-pay receivables teamand other organization members whohandle point-of-service interactionwith incoming patients. To get officestaff to buy into such a program, thepractice manager must clearly commu-

REIMBURSEMENT

How to Increase CollectionsWhile Preserving Patient RelationshipsBy David G.Morrisey, director of development, KeyBridge Medical Revenue Management

David Morrisey, KeyBridgeMedical Revenue Management’s(www.keybridgemed.com) directorof development, has over 30 yearsof experience in health care andmanagement training. He teachesseminars and courses around thecountry on effective communica-tion skills and the keys to motiva-tion. He is a member of theMedical Group ManagementAssociation, the HealthcareFinancial Management Assoc-iation, the Orthopedic ManagersAssociation, the Michigan PatientAccounting Association, and theMichigan Association of Health-care Access Professionals.

nicate and demonstrate that the prac-tice will:• Make self-pay a priority;• Improve front-end training to removeany discomfort among staff in askingfor payment;• Set collection goals and rewardachievement;• Enhance screening of patients for eli-gibility in government programs; and• Improve financial counseling servicesby expanding payment opportunities,providing discounts for patients whopay promptly, setting policies thatsupport upfront payment for electiveservices, and making back-end col-lections a priority.Only when everyone

understands the impor-tance of both point-of-ser-vice collection and follow-up collection will notice-able improvement be seenin a practice’s accountsreceivables.

Outsourcing ExpertiseImplementing an effective, compre-hensive point-of-service collection sys-tem is a big job. It’s critical to develop aprocess that is tailored to the needs ofthe practice, gets the necessary staff

buy-in, and pre-serves patient rela-tionships. Each prac-tice’s managershould consideridentifying a sea-soned accountsreceivable manage-ment partner with aproven track recordof establishing andmanaging point-of-service training and collection as wellas follow-up collection to review thepractice’s collection procedures.Where no one on a practice’s staff is

trained to provide such services, theycan be provided by outside firms thatspecialize in accounts collectable. Suchfirms can provide a practice’s point-of-service and collections teams with thetraining and tools necessary to improvethe practice’s collection effectiveness

while providing a satisfactory experi-ence for the patients. According toresearch done by KeyBridge MedicalRevenue Management, practices that

switched to a patient-friendly script designed tomotivate payment enjoyeda 100% increase in patientaccounts establishing pay-ment plans; a 90% increasein patients making imme-diate point-of-service pay-ments; a 50% decrease in

patient complaints regarding collec-tions; and a 17% increase in patientsacknowledging their ability to pay.Both the practice and the patients ben-efit from these outcomes. In the cur-rent unsettled economy, who isn’t upfor that?�


It would be a mistake for a medical practice manager to thinkthat the major obstacle in health care debt collection stems inmost cases from patients’ inability to pay their outstanding

bills, particularly their deductibles and co-pays. According toresearch by KeyBridge Medical Revenue Management, approxi-mately 65% of bad debt comes from patients who carry insur-ance. About 50% of patients with “written off” accounts actual-ly have the ability to pay in full.The real problem is that both the patient and, to a large extent,

the practice’s staff are uncomfortable with the process ofcollecting these deductibles and co-pays up front. The staff aren’tused to doing it; to them it seems almost patient-unfriendly.Even though it might be the practice’s policy, in many practicesthey haven’t been trained to collect deductibles and co-pays

effectively. As a result, the practice’s internal collection mandatesaren’t enforced.The patients themselves can exacerbate this difficulty. They

have not been conditioned through experience to being asked topay for health care at the point of service. In this situation, beingasked to pay up-front triggers the fight or flight response.Combative patients are likely to accuse the institution of caringmore about collecting money than treating the patient.The primary challenge for the practice manager is two-fold.

First, he or she must change the way the patient thinksabout the financial obligation, moving them from being ablebut unwilling to pay to being willing. Second, the managermust make certain the office staff is adequately trained andprepared to handle patients’ responses to their efforts tocollect payments. —DGM

SUCCESSFUL COLLECTIONS REQUIRE A TWO-PRONGED APPROACH

REIMBURSEMENT


In this volatile environment, medicalpractice staff members who collectmoney at the beginning and end of

service have their work cut out for them.


T he patient-centered medicalhome (PCMH) is a care modelthat places an emphasis on care

being easily accessible to patients, coor-dinated, comprehensive, and continu-ously improved through a systemsapproach. One of the most importantagencies in establishing the criteria forthe formation and credentialing ofPCMHs is theWashington, D.C.-basedaccreditation and benchmarking groupNational Committee on QualityAssurance (NCQA). According to apress release on the NCQA Web site(www.ncqa.org), “Research shows thatmedical homes can leadto higher quality andlower costs, and improvepatients’ and providers’reported experiences ofcare.”The NCQA on January

31 released its revisedstandards for the estab-lishment of PCMHs,PCMH 2011. BecausePCMH recognition is one of NCQA’slargest andmost rapidly expanding ser-vices, the updated standardswill affect alarge number of physicians and prac-tices that have already received recogni-tion. “As of the end of 2010, almost7,700 clinicians at more than 1,500 sitesacross America used NCQA standardsas a roadmap to become high-qualityprimary care practices and receiveNCQA recognition as patient-centeredmedical homes,” the press release says.

What Has ChangedAccording to the NCQA press release,PCMH 2011 will require PCMHs to beeven more patient-centered, placing anemphasis on the use of patient feed-back. “To an unprecedented degree,PCMH 2011 directs practices to orga-nize care according to patients’ prefer-

ences and needs,” the release says. Thisincludes involving patients and theirfamilies to a greater degree in the man-agement of patients’ care, providingmultilingual services, aiding andencouraging patients to participate intheir own self-care, and making caremore accessible both during and afterthe practice’s office hours.“NCQA is collaborating with the

Agency for Healthcare Research andQuality to develop amedical home ver-sion of the Consumer Assessment ofHealthcare Providers and Systems(CAHPS) Clinician & Group Survey”in order to facilitate the collection of

patient feedback, NCQA reports.CAHPS should be released in the sec-ond half of 2011, and patients will beable to receive additional NCQADistinction when they report patientfeedback voluntarily, the report says.PCMH 2011 also includes new stan-

dards for parental decision-making forchildren, and for privacy for teenagers.The new standards are designed toreinforce federal “meaningful use”requirements for health informationtechnology, the report says. “The stan-dards’ alignment with meaningful usecreates a virtuous cycle: practices thatmeet PCMH 2011 requirements will bewell prepared to qualify for meaningfuluse, and vice versa,” it says.The new NCQA standards can be

downloaded through the NCQA Website. The electronic publication can be

downloaded for free at www.ncqa.org/view-pcmh2011.

NCQA PCMH ResourcesIn addition to the document listing thenew PCMH standards, NCQA hasnumerous PCMH resources on its Website. These include links for PCMHpro-gram information such as the recogni-tion process, a PCMH 2011 Contentand Scoring Summary, a PCMH 2011overview, a training program, and apricing fee schedule. The overview,which is in the form of an 11-page PDFdocument, analyzes growth trends forPCMH recognition, geographic distrib-

ution, and consumerand public perceptionsof PCMHs. In additionto listing the standardsfor PCMH recognition,it includes a compre-hensive breakdown ofthe six levels of recogni-tion, with a detaileddescription of what each

level entails.Additional resources on the site

include links to a GovernmentRecognition Initiative for PCMHs andthe Health Resources ServicesAdministration (HRSA) and HRSAFAQs. Links to the Centers forMedicare & Medicaid Services (CMS)and Military Health Services (MHS)are coming soon.PCMH2011 publications can also be

ordered. These include a free PDF ofPCMH2011 Standards andGuidelines,application materials for PCMH 2011,and a PCMH survey tool, which mustbe purchased. Physicians and practicesseeking to form PCMHs will find thatthe NCQA is able to provide most ofthe guidance they will need to get start-ed with the process.�—Editor Rev DiCerto

MEDICAL HOMES

NCQA’s New PCMH StandardsCall for Increased Patient-Centeredness

Because PCMH recognition is one ofNCQA’s largest and most rapidly expandingservices, the updated standards will affect alarge number of physicians and practicesthat have already received recognition.


T he American MedicalGroup Association (AMGA;www.amga.org) announced in

January that the database of its EmployeeSatisfaction and EngagementBenchmarking Program recently sur-passed 10,000 employees from 20 differ-ent medical groups. Launched in 2009,the program provides medical groupswith a cost-effective tool to measure andbenchmark the job attitudes of back- andfront-office personnel and non-physi-cian professionals. Participating groupscome from across the country and varyin size from 100 to more than 2,500employees.The programwas designed by AMGA

staff using input from an advisory com-mittee composed of medical group rep-resentatives. The Web-based surveyincludes questions focused on tendimensions: employee engagement,growth opportunities, health benefits,leaves, pay, personal relationships, physi-cian interactions, rewarding work,supervision, and workload. Thesedimensions and AMGA’s survey meth-

ods result in a detailed report starting atthe overall organizational level and pro-viding breakouts at the supervisor, jobcategory, and site levels. This reportallows participating medical groups toeasily identify where improvements canbe made.Findings since the survey’s inception

include:• Overall, 28% of responding employeesindicated they were very satisfied withtheir jobs. Additionally, 26% agreedthat they would highly recommendtheir company to friends and family.• Employees over 30 years old weremoresatisfied with their jobs than youngeremployees. Overall job satisfactionwas also significantly higher foremployees in management than non-managers. Employee engagement wassignificantly higher for managers thannon-managers.• Employee engagement and overall sat-isfaction were strongly correlated withone another. The best predictors ofindividual satisfactionwere the reward-ing work and supervision dimensions.

PRACTICE MANAGEMENT NEWS

AMGA Employee Satisfaction DatabaseExceeds 10,000 Health Care Employees

The Taconic Health Information Network and Community(THINC) in January announced the launch of a series of edu-cational events to explore care delivery and reimbursement

under accountable care organizations (ACOs). Supported by agrant from the New York State Health Foundation, ACO Insightsis a training and technical assistance program designed to offerphysician practices, health plans, hospitals and other health facil-ities in the Hudson Valley an opportunity to explore the key con-cepts of and consider the development of ACOs.Beginning in 2012, Medicare will fund pilot projects to test the

model for its beneficiaries. Across the nation, provider groups,hospitals and insurance companies are exploring how to success-fully structure these new models. ACO Insights webinars will

feature high-level discussions based on a framework of ACOmodel components: financial and legal, leadership and opera-tions, quality measures and improvement, and engagement.ACO Insights will begin with a series of free 90-minute webi-

nars offering opportunities for registrants to ask questions ofnationally recognized experts. THINC is a not-for-profit organiza-tion that seeks to convene providers, payers, employers, publichealth agencies, quality organizations, consumers and local lead-ers to improve the quality, safety and efficiency of health care forthe Hudson Valley community.More information about ACO Insights is available at

http://thinc.org/aco-insights.html.

N.Y. ORGANIZATION OFFERS ACO LEARNINGAND TECHNICAL ASSISTANCE EFFORT FOR PROVIDERS

Most commercial health insur-ance markets in the UnitedStates are dominated by one or

two health insurers, the 2010 edition ofCompetition in Health Insurance: AComprehensive Study of U.S. Markets,released February 1 by the AmericanMedical Association (AMA; www.ama-assn.org), indicates. Based on 1997U.S. Department of Justice and FederalTrade Commission Horizontal MergerGuidelines, 99% of U.S. health insur-ance markets are “highly concentrat-ed,” indicating a significant absence ofcompetition among insurers, the reportfinds. In 48% of metropolitan areas, atleast one insurer had a market share of50% or more, it says. “When insurersdominate a market, people pay higherhealth insurance premiums than theyshould, and physicians are pressuredto accept unfair contract terms and cor-porate policies, which undermines thephysician role as patient advocate,”said AMA President Cecil B.Wilson, MD.

AMA STUDY FINDSMOST MARKETSDOMINATED BYONE OR TWOHEALTH INSURERS

Many patients express confu-sion over the qualificationsof different health care pro-

fessionals, according to survey resultsannounced in January by theAmericanMedical Association (AMA). Although83% of patients surveyed want a physi-cian to have primary responsibility fortheir health care, many are confusedabout the qualifications of health careprofessionals, the survey indicates. Thetelephone survey was conductedamong 850 adults nationwide byBaselice &Associates. The overall mar-gin of error is +/- 3.4% at the 95% level.“A physician-led team approach to

care with each member of the healthcare team playing the role they are edu-cated and trained to play is key to ensur-ing patients receive high quality care,

and most Americans agree,” said AMABoard Member Rebecca Patchin, MD.“Although 90% of those surveyed saidthat a medical doctor’s additional yearsof education and training are vital tooptimal patient care, the survey foundmuch confusion about the qualifica-tions of health care professionals.”The survey also finds that 87% of

respondents would support legislationrequiring health care advertisements todesignate the qualifications of the pro-fessionals promoting their services. Inan effort to help alleviate confusion, theHealthcare Truth and TransparencyAct of 2011, introduced in January,prohibits misleading and deceptiveadvertising by health care profession-als. Several states have already enactedsimilar legislation.

Survey: PatientsWant Physicians to LeadCare, Express Confusion OverQualifications


The American Medical Association (AMA) in January announced that to help physi-cians receive reimbursements for the Center for Medicare and Medicaid Services(CMS) Physician Quality Reporting Initiative (PQRI) program, it is working with

health information technology provider Covisint to allow eligible physicians to usethe DocSite PQRI Web application (www.covisint.com/web/guest/healthcare/docsitepqri). The self-service Web application enables physicians to securely submitdata for 2010 PQRI reporting. AMA members are eligible to subscribe to this service ata discounted rate.“Covisint DocSite helps physicians easily apply for PQRI incentive payments by

cutting through administrative and technological complexity,” said AMA SeniorVice President Bob Musacchio. CMS offers incentives for eligible physicians whosatisfactorily report data on quality measures for covered professional services toMedicare beneficiaries. Participation is voluntary and 2010 is the last year for whichCMS will pay 2% of Medicare fees for PQRI participation. In 2011, the incentivepercentage is expected to decrease.

AMA, HEALTH IT FIRM FACILITATEREPORTING OF PQRI DATA

Primary care and specialist physi-cians have different views abouthow often their colleagues com-

municate with them, a study byresearchers at the Washington, DC-based Center for Studying HealthSystem Change (HSC;www.hschange.com) published in theJanuary 10 Archives of InternalMedicine indicates. Among primarycare physicians (PCPs), 69.3% report-ed “always” or “most of the time”sending a patient’s history and the rea-son for the referral to the specialist,but only 34.8% of specialists said theyregularly receive such information, thestudy found.Among specialists, 80.6%said they regularly send consultationresults to the referring PCP, but only62.2% of PCPs said they received theresults, it found.Physicians who did not receive time-

ly communication regarding referralsand consultations were more likely toreport that their ability to providehigh-quality care was threatened, thestudy found. For both PCPs and spe-cialists, adequate time with patientsduring an office visit was the mostimportant factor in whether physicianswere more likely to report sending andreceiving information about referralsand consultations, the study found.The study, “Referral and

Consultation Communication BetweenPrimary Care and Specialist Physicians:Finding Common Ground,” is based onHSC’s 2008 Health Tracking PhysicianSurvey, which collected informationfrom 4,720 practicing physicians. Thesurvey had a 62% response rate andwas funded by the Robert WoodJohnson Foundation.

STUDY: COMMUNICATIONDISCONNECT BETWEENPCPS, SPECIALISTS

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