Overdoing and underdoing it on #HIPPA, patient privacy

Friday’s “New Old Age” column in the The New York Times suggests tha HIPPA privacy rules are applied inconsistently.

ssIt’s become an all-purpose excuse for things people don’t want to talk about,” said Carol Levine, director of the United Hospital Fund’s Families and Health Care Project, which has published a HIPPA  guide for family caregivers.

Within families, decisions about how much health information to share, and with whom, often become complicated, as a recent study in JAMA Internal Medicine found. When researchers working to design online patient portals convened two sets of focus groups — one for people over age 75, another for family caregivers — they heard the usual tension between older adults’ need for assistance and their desire for autonomy.

“Seniors say, ‘I don’t want to burden my kids with my medical issues,’ ” said Bradley Crotty, the director of patient portals at Beth Israel Deaconess Medical Center in Boston and the study’s lead author. “And the family is saying, ‘I’m already worried. Not knowing is the burden.’ ”

The older group wanted help but not second-guessing or “spying,” Dr. Crotty added. They might agree to disclose the medications they take — just not all of them.

Moreover, the dynamic often changes with increasing disability or a health crisis.

“Say a senior has a serious medical condition — a stroke, for instance — and requires a lot of help and support,” Dr. Crotty said. “He could recover enough to want to take back control of his health information. It may go back and forth.”

Also note that the new Health Wonk Review is up at the Insure Blog.

Will the feds improve the quality of #nursinghome care? #longtermcare

The Boston Globe’s reporting on conditions in MA nursing homes suggests the need for reform.khn-logo1

From Kaiser Health News:

After nearly 30 years, the Obama administration wants to modernize the rules nursing homes must follow to qualify for Medicare and Medicaid payments.

The hundreds of pages of proposed changes cover everything from meal times to use of antipsychotic drugs to staffing.  Some are required by the Affordable Care Act and other recent federal laws, as well as the president’s executive order directing agencies to simplify regulations and minimize the costs of compliance.

“Today’s measures set high standards for quality and safety in nursing homes and long-term care facilities,” said Health and Human Services Secretary Sylvia M. Burwell. “When a family makes the decision for a loved one to be placed in a nursing home or long-term care facility, they need to know that their loved one’s health and safety are priorities.”

Officials announced the update as the White House Conference on Aging convenes Monday.  The once-a-decade conclave sets the agenda for meeting the diverse needs of older Americans, including long-term care options.  This month also marks the 50th anniversary of the Medicare and Medicaid programs, which cover almost 125 million older, disabled or low-income Americans. Medicare and Medicaid beneficiaries make up the majority of residents in the country’s more than 15,000 long-term care facilities.

“The existing regulations don’t even conceive of electronic communications the way they exist today,” said Dr. Shari Ling, Medicare’s deputy chief medical officer. “Also there have been significant advances in the science and delivery of health care that just weren’t imagined at the time the rules were originally written. For example, the risks of anti-psychotic medications and overuse of antibiotics are now clearly known, when previously they were thought to be harmless.

The proposed regulations include  a section on electronic health records and measures to better ensure that patients or their families are involved in care planning and in the discharge process.  The rules also would strengthen infection control, minimize the use of antibiotic and antipsychotic drugs and reduce hospital readmissions.

Revised rules would also promote more individualized care and help make nursing homes feel more like home.  For example, facilities would be required to provide “suitable and nourishing alternative meals and snacks for residents who want to eat at non-traditional times or outside of scheduled meal times.”

Residents should also be able to choose their roommates.  “Nursing facilities not only provide medical care, but may also serve as a resident’s home,” the proposed rules say. “Our proposed provision would provide for a rooming arrangement that could include a same-sex couple, siblings, other relatives, long term friends or any other combination” as long as nursing home administrators “can reasonably accommodate the arrangement.”

Consumer advocates are likely to be disappointed that officials are not including recommendations to set a federal nurse-to-resident ratio.

However, the proposed changes would require that nurses be trained in dementia care and preventing elder abuse to better meet residents’ needs.

“We believe that the focus should be on the skill sets and specific competencies of assigned staff,” officials wrote in the proposed rules, “to provide the nursing care a resident needs rather than a static number of staff or hours of nursing care that does not consider resident characteristics.”

Nursing homes will be required to report staffing levels, which Medicare officials said they will review for adequacy.

“It’s a competency approach that goes beyond a game of numbers,” said Ling. “If residents appear agitated, figure out why, get at the cause of the problem,” she said, instead of resorting to drugs to sedate residents.

Advocates for nursing home residents argue that because of inadequate staffing, residents with dementia are often inappropriately given antipsychotic drugs, even though that can be dangerous for them. The new rules would help control the use of these drugs by requiring the facility’s pharmacist to monitor drugs that are prescribed for excessive periods of time or other irregularities and require the resident’s physician to address the problem or explain in the resident’s medical record why the medication is necessary.

“We don’t have enough nursing staff,” Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy, said before the rules were released.  Federal law requires only one registered nurse on the day shift for a 20-bed facility or a 500-bed facility, licensed practical nurses around the clock and sufficient staff to meet residents’ needs, she said.

“We don’t look at the specific staffing positions per se,” said Greg Crist, a spokesman for the American Health Care Association, which represents 11,000 skilled nursing facilities.  “We look at the needs of the individuals when determining staff levels, and that is best addressed in the resident’s care plan.”

Although there are also no provisions addressing enforcement in the proposed rule, Ling said  it “will permit detection of violations to enable enforcement  by lessening the noise.”

“The biggest problem is that the rules we have now are not enforced,” said Edelman.  “We have a very weak and timid enforcement system that does everything it can to cajole facilities into compliance instead of imposing penalties for noncompliance.”

A report by the Center for Medicare Advocacy last year found that some serious violations often were not penalized.

“Once the new rules are finalized, they will be added to the items nursing home inspectors check,” Ling said.

Kaiser Health News (KHN) is a nonprofit national health policy news service. 

Harvard health policy researcher in NYTimes story: Can virtual office visits cut healthcare costs? #hcr #telemedicine

No surprises in the growth of online health services. And while telemedicine and various forms of virtual visits abound, researchers are still gauging the impact on quality and costs.

Harvard researcher Ateev Mehrorta has been following the trend. He’s quoted in Saturday’s New York Times story on video consults

Even as virtual visits multiply, researchers say it is not clear whether they really save money or provide better outcomes..

Virtual urgent care visits are undoubtedly less expensive than trips to the emergency room, said Dr. Ateev Mehrotra, a professor of health policy at Harvard Medical School, who has studied telemedicine. “But I think it’s very plausible, and probably likely, that a lot of people who do a virtual visit would otherwise have stayed home,” Dr. Mehrotra said, pointing to research that suggests most people do not end up seeking care when they feel sick. “So it could increase health care spending over all.”

In May 2014, he spoke before the U.S. House of Representatives Energy and Commerce Committee’s Subcommittee on Health during a hearing on Telehealth to Digital Medicine: How 21st Century Technology Can Benefit Patients on May 1, 2014.

From ProPublica: Should drug companies report payments to non-doc prescribers?

 

Transparency Program Obscures Pharma Payments to Nurses, Physician Assistants

New data on drug and device company payments to doctors largely excludes nurse practitioners and physician assistants, though they play an ever-larger role in health care. One advanced-practice nurse pleaded guilty last month to taking drug company kickbacks.

propub logoA nurse practitioner in Connecticut pleaded guilty in June to taking $83,000 in kickbacks from a drug company in exchange for prescribing its high-priced drug to treat cancer pain. In some cases, she delivered promotional talks attended only by herself and a company sales representative.

But when the federal government released data Tuesday on payments by drug and device companies to doctors and teaching hospitals, the payments to nurse practitioner Heather Alfonso, 42, were nowhere to be found.

That’s because the federal Physician Payment Sunshine Act doesn’t require companies to publicly report payments to nurse practitioners or physician assistants, even though they are allowed to write prescriptions in most states.

Nurse practitioners and physician assistants are playing an ever-larger role in the health care system. While registered and licensed practice nurses are not authorized to write prescriptions, those with additional training and advanced degrees often can.

A ProPublica analysis of prescribing patterns in Medicare’s prescription drug program, known as Part D, shows that these two groups of providers wrote about 10 percent of the nearly 1.4 billion prescriptions in the program in 2013. They wrote 15 percent of all prescriptions nationwide (not only Medicare) in the first five months of the year, according to IMS Health, a health information company.

For some drugs, including narcotic controlled substances, nurse practitioners and physician assistants are among the top prescribers.

“Nurse practitioners see patients, order tests, recommend procedures and prescribe medications,” Dr. Walid Gellad, an associate professor of medicine at the University of Pittsburgh and co-director of its Center for Pharmaceutical Policy and Prescribing, wrote in an email. “It seems straightforward to think that their relationships with the pharmaceutical and device industries are of as much relevance as physicians, dentists, chiropractors, etc.”

He added, “If the purpose of the act is to shine a light on the relationship between industry and the health care sector, then you’ve left out an important component of that sector.”

When the Sunshine Act was drafted, those involved say, nurse practitioners weren’t part of the discussion. “Physician groups were among the stakeholders who were very engaged,” said Allan Coukell, senior director for health programs at the Pew Charitable Trusts. “Nursing groups weren’t part of the policy discussions and weren’t ultimately covered by the law.”

Still, Coukell said, “To the extent that a lot of prescribing now is done by health professionals who aren’t physicians, and a lot of marketing is directed at them, they ideally should also be part of the disclosure.”

Asked whether payments to these providers should be reported, a spokesman for the Centers for Medicare and Medicaid Services, which manages the disclosure system, said: “Nurse practitioners and physician assistants are currently not covered recipients under the statute for Open Payments.”

A representative of the Pharmaceutical Research and Manufacturers of America, the industry trade group, declined comment.

Although payments to nurse practitioners are not required to be reported under the law, a handful of companies did so anyway. Of the 606,000 providers who received payments in 2014, several hundred self-identified as nurse practitioners or physician assistants. The rest were doctors, dentists, optometrists, podiatrists and chiropractors. (Some of the self-identified nurse practitioners and physician assistants actually appear to be doctors, but have misclassified themselves.)

Alfonso was employed as an advanced-practice nurse at Comprehensive Pain and Headache Treatment Center in Derby, Connecticut. An investigation revealed that she was a heavy prescriber of Subsys, an expensive drug used to treat cancer pain, the U.S. Attorney’s Office for Connecticut said. Between January 2013 and March 2015, she wrote more than $1 million in Subsys prescriptions to Medicare patients alone, more than any other prescriber in Connecticut, prosecutors alleged.

“Interviews with several of Alfonso’s patients, who are Medicare Part D beneficiaries and who were prescribed the drug, revealed that most of them did not have cancer, but were taking the drug to treat their chronic pain,” the U.S. attorney’s office said in a press release.

Prosecutors said Alfonso was paid as a promotional speaker by Subsys’ maker, Insys Therapeutics Inc., for more than 70 dinner programs at a rate of about $1,000 per event. “In many instances, the dinner programs were only attended by Alfonso and a sales representative for the drug manufacturer,” the U.S. attorney said in the release. “In other instances, the programs were attended by individuals, including office staff and friends, who did not have licenses to prescribe controlled substances. For the majority of these dinner programs, Alfonso did not give any kind of presentation about the drug at all.”

The charge against Alfonso carries a maximum sentence of five years in prison and a fine of up to $250,000. Sentencing is scheduled for September.

Alfonso could not be reached for comment and her attorney has not returned a phone call. A phone call to Insys was also not returned, though the company said in a statement to The New York Times that it was committed to promoting Subsys “lawfully and appropriately.”

A ProPublica report last year identified Alfonso as among the top 20 prescribers nationally of the most-potent controlled substances within Medicare’s Part D program in 2012. At the time, we noted that she had been reprimanded and fined by the Connecticut health department in July 2014 for allegedly failing to examine a patient before prescribing/refilling narcotics.

Elissa Ladd, an associate professor of nursing at the MGH Institute of Health Professions in Boston, surveyed 263 nurse practitioners several years ago about their interactions with the pharmaceutical industry. Her survey, published in 2010 in the American Journal of Managed Care, found that nearly all had regular contact with drug company sales representatives. Nine in 10 believed that it was acceptable to attend lunch and dinner events sponsored by the industry.

Ladd said she supports mandatory disclosure of payments for nurse practitioners and physician assistants.

“Nurse practitioners think that they’re somewhat immune to this but I think that we’re no different than any other provider,” she said. “If nurse practitioners were reported on, I think that would be a huge concern for them. I don’t think they want to be perceived in a negative light.”

Look up your doctor in our Dollars for Docs interactive database to see if he or she has received payments from drug or device companies in 2013–2014. Also read our story about doctors who had the most interactions with the industry.

Kings, dogs and Burwells: The latest policy posts from the Health Wonk Review #HWR

BHN is hosting this week’s round-up. In anticipation of the King v. Burwell decision, we offer kings and Burwells. The content of the images is not meant as a BHN endorsement for either position. Same goes for the opinions in these posts. Some say the ruling may come down today, others bet on 6/29. SCOTUS Blog is the site to watch. (For actual posts on the pending decision, see the 6/3 edition.)

Finally, our thoughts are with the members of Emanuel African Methodist Episcopal Church and the staff at one more hospital that had to brace for victims of a mass shooting.

The posts:

  • 512px-BBKing07

    By Roland Godefroy

    Joseph Paduda at Managed Care Matters writes:  Health care cost drivers; or, here’s where you’re getting screwed. Two studies published in Health Affairs shed much light on hospital costs and the societal implications of physician practice consolidation.  Both are a bit scary.

  • A post from Health Affairs analyzes the major elements of the final rule recent Medicare Shared Savings Program Final Rule.Lawrence Kocot, of Ross White,
    burwell

    HHS photo

    and Mark McClellan at KPMG  offer alternatives for CMS and the possible future of the program

  •   From David Willams at the Health Business Blog notes: Long term care insurance -narrow framing is not the problem. Why don’t people buy long term care insurance? Because for many it’s not a good value
  •  David Harlow at the HealthBlawg: Outsourced Chronic Care Management Service256px-King_Kong_1933_French_posters Can Help Physicians and Patients. I wrote this post with a client about Chronic Care Management, a newly-reimbursable service under Medicare as of January 2015, and a service that is specifically non-face-to-face. The federales are dedicating significant funds to this service based on the belief that it will reduce expenditures on other services for multiply-chronically-ill elders.
  • From Boston Health News, links to stories on telemedicine and hospitals as step-down units.
  • From Roy Poses at Health Care Renewal: Health Care Professional Societies Whose Leadership Betrays Their Own Members – the APA Alleged to Have Supported Torture, and Deceived its Members to Collect Money. Health care professionals need to be extremely skepticburwellneonal of the leadership and governance of all health care organizations.  True health care reform requires organizational leaders who understand the health care system, uphold its values, and are willing to be accountable.
  •  Tom Lynch of Workers Comp Insider offers “the word of the week: horrendoma. That’s a description he applies to the healthcare system after looking at billed vs paid hospital data and the concept of charges as a “starting point.” See his post: Hospital Medicare Charges: You Don’t Always Get What You Want.
    By Metro-Goldwyn-MayerReproduction Number: LC-USZ6-2067 Location: NYWTS -- BIOG [Public domain], via Wikimedia Commons

    By Metro-Goldwyn-Mayer, Inc.

  • Henry Stern at InsureBlog asks “What carrier in its right mind would cover” sex change surgery? Transjenner Insurance: In case you were wondering: Yes, ObamaPlans *do* cover sex-changes. InsureBlog has the, er, straight scoop.
  • From Health System Ed: Decrying the End of Private Physician Practice? Not so fast!  Experts have been saying that the private physician practice is no longer sustainable under managed care but then along comes ACOs and perhaps that tune is changing when the focus turns from volume to outcomes.
  • This Health Affairs post focuses specifically on the provisions of the rule dealing with benchmarkingBWburwell2 and distribution of shared savings and losses and suggests that CMS consider the possibility of graduated rates of sharing savings and loss distribution.y Carrie Colla, Scott Heiser, Emily Tierney, and Elliott Fisher at Dartmouth
  • Finally, Brad Wright asks : This Father’s Day, Give 1 For Dad
    In honor of his father, he’s donating to “Give 1 For Dad campaign to fund an important clinical trial for prostate cancer at the Duke Cancer Institute. At issue is that the treatment uses a safe generic drug, which is great because it isn’t toxic like other current treatments, but not so great because no major pharmaceutical companies are willing to fund a clinical trial of a generic drug.”

What does your king look like? king-cobra-405623_640(Click on images for credits, rights.)

Cavalier_King_Charles_Spaniel_Floral

My latest from Health Leaders: disparities, quality & TripleAim

by Nora Valdez. Click for more.

by Nora Valdez. Click for more.

Fueled by the financial incentives built into the healthcare reform law, the Institute for Health Improvement’s concept is generating meaningful changes in the way healthcare is delivered, research finds.

Value-based care brings new urgency to the effort to end disparities in healthcare access and outcomes for minorities.

Boston voices in stories on telemedicine and hotels as hospital step-down units

Some Boston links in these story from Health Leaders Media.

connected healthIn a story about telemedicine, Joseph Kvedar, MD, vice president of the Partners’ Center for Connected Health in Boston, says that at two recent health industry meetings “every panel and every conversation had something on telemedicine and virtual visits.” Telemedicine is taking off, but there is resistance from regulators in at least one state, and stubborn questions about reimbursement and efficacy in general.

This column about hospitals discharging patients to hotels starts in Boston and heads out westHLM:

The Wyndham Beacon Hill hotel uses its proximity to Massachusetts General Hospital as a marketing tool. The hotel website includes a hospitals page featuring a blonde model in a white coat with a stethoscope around her neck. The hotel offers a link to each of the city’s hospitals, discounted rates for patient families, and access to a shuttle bus.  

The Wyndham isn’t alone. Often, patients have to travel long distances to places like Boston for specialized care. So hotels have grown up around large hospitals to offer shelter to caregivers. And sometimes patients, too sick to travel home or waiting for follow-up care, need a night or two of lodging as well.

But hospitals have different protocols—or none at all—when it comes to discharging patients to hotels. And hotels have different capacities for hosting them.

But the Occupational Safety and Health Administration’s bloodborne pathogens standard applies to all.

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