Background Image

Physicians News Spring 2014 : Page 1

PHYSICIANS NEWS Digest PhysiciansNews.com SPRING 2014 OLD-FASHIONED PHYSICAL EXAM DIAGNOSIS Doctors at a Northern California hospital, concerned that a 40-year-old woman with sky-high blood pressure and confusion might have a blood clot, order a CT scan of her lungs. To their surprise, the scan reveals not a clot but large cancers in both breasts that have spread throughout her body. Had they done a simple physical exam of the woman's chest, they would have been able to feel the tumors. So would the doctors who saw her during several hospitalizations over the pre-vious two years, when the cancer might have been more easily treated. A middle-aged man admitted to a Seattle emergency room for the third time in six weeks displays the classic signs of liver cirrhosis for which he has been repeatedly treated, including swollen legs and a distended abdomen. But a veteran doctor spots a tell-tale indicator of a different disease: rapid inward pulsations just beneath the man's right ear. The patient's problem is not his liver but his heart: he has constrictive pericarditis, a se-rious condition that requires surgery. Both cases reflect a phenomenon that some prominent medical educa-tors say has become increasingly com-monplace as medicine becomes more technology-driven: the waning ability of doctors to use a physical exam to make an accurate diagnosis. Informa-tion gleaned from inspecting blood ves-sels at the back of the eye, observing a patient's walk, feeling the liver or checking fingernails can provide valu-able clues to underlying diseases or incipient problems, they say. But over the past few decades the physical diagnosis skills that were once the cornerstone of doctoring have withered, supplanted by a dizzying ar-ray of sophisticated, expensive tests. "A lot of people downplay the phys-ical exam and [wrongly] say it's fluff," said Salvatore Mangione, associate di-rector of the internal medicine resi-dency at Philadelphia's Jefferson Med-ical College and director of its physical diagnosis curriculum. In a 2012 article in the Cleveland By Sandra G. Boodman EMPHASIS ON TECH HAS ERODED THE INSIDE THI S ISSUE OPINION Why I Became A Primary Care Physician Clinic Journal of Medicine, Mangione wrote that he has seen "many cases in which technology, unguided by bed-side skills, took physicians down a path where tests begot tests and where, at the end, there was usually a surgeon, and often a lawyer. Some-times even an undertaker." See Old-Fashioned on page 2 4 LOCAL WHAT DOCTORS SHOULD KNOW ABOUT AUDITS, INVESTIGATIONS AND COMPLIANCE Recently, Inspector General Levinson outlined the Office of In-spector General’s (OIG) strategic plans for fiscal years 2014-2018 (Strategic Plan), including four goals: (i) fight fraud, waste, and abuse; (ii) promote quality, safety, and value; (iii) secure the future; and (iv) ad-vance excellence and innovation. Mr. Levinson states: For more than 30 years, OIG has consistently achieved commendable results and significant returns on in-vestment. In FY 2012 alone, OIG’s ef-forts resulted in estimated savings and expected recoveries of misspent funds totaling approximately $15.4 billion. The Health Care Fraud and Abuse Control program, of which OIG is a key partner, returned more than $7 for every $1 invested. With respect to fighting fraud, waste and abuse, the OIG’s priorities are to: (i) identify, investigate and take action when needed; (ii) hold wrongdoers accountable and maxi-mize recovery of public funds; and (iii) prevent and detect fraud, waste and abuse. The Strategic Plan identifies OIG’s strategies as follows: • using data analysis and risk as-sessments of emerging issues to identify suspected fraud, waste, and abuse and deploy our over-sight and enforcement resources; • partnering with the Department of Justice (DOJ) and the Depart-ment of Health and Human Serv-ices (HHS) on Medicare Fraud Strike Force teams and other PRST STD US Postage Paid Permit No. 397 Bellmawr, NJ By John W. Jones , Jr., Esq. 8 Q: This Residency Program is a 6-Time Champion; A: What is “Einstein?” Federal government auditors will assist OIG with its priorities and im-plementing strategies. An audit of a physician or physician group is often triggered based on data that is out-side of the norm of the physician group, such as utilization, medical ne-cessity or lack of documentation as well as billing errors identified in a particular federal government study such as the Comprehensive Error Rate Testing (CERT) study (which led to CERT audits). The Recovery Audit Contractors (RACs) audits were started as part of a demonstration program under the Medicare Modern-ization Act of 2003 and the purpose was to identify and correct improper Medicare payments and collect over-payments. Zone Integrity Program See Audits on page 5 health care fraud enforcement ac-tivities through the Health Care Fraud and Abuse Control (HCFAC) program; and • identifying fraud, waste and abuse vulnerabilities in HHS pro-grams and operations and advis-ing HHS program administrators and policymakers on how to im-plement effective safeguards. BUSINESS Chemo Costs In U.S. Driven Higher By Shift To Hospital Outpatient Facilities 10 Classifieds. . . . . . . . . . . . . . . . . . . . . . . . . . 15 Business . . . . . . . . . . . . . . . . . . . . . . 6, 10, 12 DEPARTMENTS Local . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Opinion . . . . . . . . . . . . . . . . . . . . . . . . . . . 4, 13 Medical News . . . . . . . . . . . . . . . . . . . . . . 6-7

Emphasis On Tech Has Eroded The Old-Fashioned Physical Exam Diagnosis

Sandra G. Boodman

Doctors at a Northern California hospital, concerned that a 40-year-old woman with sky-high blood pressure and confusion might have a blood clot, order a CT scan of her lungs. To their surprise, the scan reveals not a clot but large cancers in both breasts that have spread throughout her body.

Had they done a simple physical exam of the woman's chest, they would have been able to feel the tumors. So would the doctors who saw her during several hospitalizations over the previous two years, when the cancer might have been more easily treated.

A middle-aged man admitted to a Seattle emergency room for the third time in six weeks displays the classic signs of liver cirrhosis for which he has been repeatedly treated, including swollen legs and a distended abdomen.

But a veteran doctor spots a telltale indicator of a different disease: rapid inward pulsations just beneath the man's right ear. The patient's problem is not his liver but his heart: he has constrictive pericarditis, a serious condition that requires surgery.

Both cases reflect a phenomenon that some prominent medical educators say has become increasingly commonplace as medicine becomes more technology-driven: the waning ability of doctors to use a physical exam to make an accurate diagnosis. Information gleaned from inspecting blood vessels at the back of the eye, observing a patient's walk, feeling the liver or checking fingernails can provide valuable clues to underlying diseases or incipient problems, they say.

But over the past few decades the physical diagnosis skills that were once the cornerstone of doctoring have withered, supplanted by a dizzying array of sophisticated, expensive tests.

"A lot of people downplay the physical exam and [wrongly] say it's fluff," said Salvatore Mangione, associate director of the internal medicine residency at Philadelphia's Jefferson Medical College and director of its physical diagnosis curriculum.

In a 2012 article in the Cleveland Clinic Journal of Medicine, Mangione wrote that he has seen "many cases in which technology, unguided by bedside skills, took physicians down a path where tests begot tests and where, at the end, there was usually a surgeon, and often a lawyer. Sometimes even an undertaker."

To address the problem, programs to revive and teach physical diagnosis - also known as bedside medicine - are underway at some medical schools, including Stanford, Jefferson and Johns Hopkins. The programs are predicated on a belief that these skills are an essential adjunct to technology and can boost diagnostic accuracy, curb unnecessary and expensive testing and foster a greater connection between patients and doctors, many of whom spend increasing amounts of their day staring at their computers rather than looking at the patients they are treating.

At Hopkins, a Web-based program called Murmurlab.Org seeks to improve young doctors' ability to use a stethoscope -- a tricky skill that studies have shown is lacking - to distinguish serious cardiac problems from far more common benign heart murmurs.

The goal is to reduce unnecessary and costly echocardiograms.

"There are two reasons it remains crucial to do this [physical diagnosis] at least as well as doctors did 100 years ago," said internist and best-selling author Abraham Verghese, senior associate chairman of Stanford's program on the theory and practice of medicine. Verghese was instrumental in creating the six-year-old Stanford Medicine 25 program: 25 physical exam skills that students are required to learn, demonstrate and teach. These include assessing enlarged lymph nodes, measuring ankle reflexes and performing a knee exam.

"We can pick off the low-hanging fruit - the obvious diagnosis that one can miss at great cost to the patient," such as the woman whose metastatic breast cancer was repeatedly missed, Verghese said. In his view, the physical exam also represents an "important transactional moment" between doctor and patient - a laying-on of hands that helps foster trust. An increasingly common complaint from patients, he said, is that "the doctor never touched me."

Overreliance on technology, he said, has produced perverse results. "If you come to our hospital missing a finger," he quipped, "no one will believe you until we get a CT scan, an MRI and an orthopedic consult."

Differentiating heart murmurs

But some experts are skeptical that reviving the physical exam is the best approach in the 21st century. Robert Wachter, former chairman of the American Board of Internal Medicine, said he shares Verghese's concerns about declining clinical skills. But Wachter said he isn't sure that "restoring the physical exam of yore" is a solution.

"Taking time and energy to train doctors in the physical exam may be less valuable than teaching them how to communicate or to analyze . . . Data," said Wachter, associate chairman of medicine at the University of California at San Francisco. "You've got to make some choices."

There is general agreement that the technological explosion that began in the 1980s led to the decline of bedside skills.

Insurance that pays for tests but gives short shrift to a careful and time-consuming history and physical exam accelerated the trend, as has the growing paperwork burden doctors face. The generation of influential mentors who taught physical diagnosis has largely retired. Even bedside rounds - where such knowledge was often imparted to impressionable neophyte physicians -- are mostly a thing of the past, migrating from a patient's hospital bed to a conference room down the hall where test results and the chart -- not the actual patient -- are examined.

Too often, physical exam skills are dismissed as inferior relics of the past when compared with "the glitter and perceived objectiveness of modern technology," said Steven McGee, a professor of medicine at the University of Washington and the author of a recent textbook on evidence-based physical diagnosis.

McGee said that studies have found that physical exam findings can be as accurate as their technological counterparts. Case in point: A pair of studies involving 185 acutely dizzy patients found that the presence of certain abnormal eye movements were more accurate than an initial MRI scan in distinguishing a serious stroke from a benign inner ear problem.

The enormous amount of technology that doctors now must master has crowded out physical diagnosis, he said. But, he noted, "there is a giant chunk of diagnosis that still depends on what we see and detect" through observation and a physical exam.

For a surprising number of diseases, McGee added, diagnosis is based on observation and examination, not a test. Among them are Parkinson's disease, shingles, drug rashes and constrictive pericarditis.

These days, medical students often train on actors who are only pretending to have medical problems, notes Poonam Hosamani, a newly minted hospital-based internist who joined the Stanford team last year.

Hosamani said that she recently enlisted her husband, who has a bad knee, as a featured patient. Many students told her they had never seen a patient with a knee problem. "When we bring in patients with real pathologies, the students are very excited about that," she said. "We have to show them that this is worth their time and demonstrate how much information you can gain" through a good exam, which is not intended to replace technology but to guide its use.

Internist John Kugler, an assistant professor of medicine at Stanford, said that typically medical students learn diagnosis skills before they have seen patients. "They are taught where to put their hands, but these techniques are taught in isolation and there is little to no reinforcement," he said.

W. Reid Thompson, a pediatric cardiologist at Hopkins, launched Murmurlab, a website containing the normal and abnormal heart sounds of more than 1,300 people, in part to curb unnecessary referrals for echocardiograms, which cost up to $900 apiece.

Heart murmurs in children, Thompson said, are common -- between 60 and 70 percent of children have them -- but only about 1 percent are problematic. Distinguishing "innocent" murmurs from serious ones, he said, is an essential skill for physicians, not just cardiologists. But studies have repeatedly found that many doctors do a poor job with auscultation, or listening to the heart and lungs with a stethoscope.

Despite doctors' reliance on a plethora of sophisticated tests, auscultation remains "a fundamental clinical skill," Thompson says. "Every day . . . I walk up to a patient and the first thing I do is listen" to the heart. "People walk around with a stethoscope not just because it looks good or is expected, but because there is information to be learned."

But Thompson said it is not yet clear whether Murmurlab has improved doctors' skills. Stanford officials say they are attempting to devise ways to measure the impact of their program as well.

Lots of data, little interaction

In a recent essay, Arnold Relman, a former editor of the New England Journal of Medicine, described the months he spent last summer at Massachusetts General Hospital after he broke his neck in a near-fatal fall. "Doctors now spend more time with their computers than at the bedside," wrote Relman, an emeritus professor of medicine at Harvard. Reviewing records of his hospital stay, Relman "found only brief descriptions of how I felt and looked" but "copious reports of the data from tests and monitoring devices." Conversations with his doctors were "infrequent, brief and hardly ever reported."

McGee said that he once saw a nurse tell a resident that a patient had spiked a fever and watched as the young doctor frantically scrolled through the electronic medical record searching for a cause, instead of walking down the hall to the patient's room to discover the reason: an inflamed IV site.

"In most hospitals today, the average amount of time a busy intern spends with a patient is four minutes," said Brendan Reilly, who until recently was the executive vice chairman of medicine at New York-Presbyterian Hospital. No longer are tests ordered based on the results of a careful physical exam and history, Reilly said, but the "technological tests become the primary source of information on the patient. It's backward now," and the process is driving up health-care costs and subjecting patients to the risks posed by sometimes unnecessary, risky procedures.

"Doctors trained outside the U.S. are much better clinically than young American doctors," said Reilly, the author of "One Doctor," an unsparing 2013 account of his medical career. They are trained -- or forced by circumstance - - to rely less on technology and more on physical diagnosis skills.

The Stanford Medicine 25 program reflects Verghese's medical training in Ethiopia in the 1980s. Doctors were required to hone their clinical skills because technology was largely nonexistent.

"In some ways," Reilly said, "what Verghese is doing is opening people's eyes and showing that medicine can be a lot of fun."

Reilly said he hopes the accountable care organizations that are part of the new health law - groups of doctors that band together with hospitals to improve the quality of care for patients and share in cost savings - might boost the effort to revive bedside medicine. "The current system is so ridiculous and inefficient and expensive that we're going to have to go back to doing some of the old stuff."

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

Read the full article at http://www.livedigitaleditions.com/article/Emphasis+On+Tech+Has+Eroded+The+Old-Fashioned+Physical+Exam+Diagnosis/1725744/211885/article.html.

What Doctors Should Know About Audits, Investigations And Compliance

John W. Jones, Jr., Esq.

Recently, Inspector General Levinson outlined the Office of Inspector General’s (OIG) strategic plans for fiscal years 2014-2018 (Strategic Plan), including four goals: (i) fight fraud, waste, and abuse; (ii) promote quality, safety, and value; (iii) secure the future; and (iv) advance excellence and innovation. Mr. Levinson states:

For more than 30 years, OIG has consistently achieved commendable results and significant returns on investment. In FY 2012 alone, OIG’s efforts resulted in estimated savings and expected recoveries of misspent funds totaling approximately $15.4 billion. The Health Care Fraud and Abuse Control program, of which OIG is a key partner, returned more than $7 for every $1 invested.

With respect to fighting fraud, waste and abuse, the OIG’s priorities are to: (i) identify, investigate and take action when needed; (ii) hold wrongdoers accountable and maximize recovery of public funds; and (iii) prevent and detect fraud, waste and abuse. The Strategic Plan identifies OIG’s strategies as follows:

• using data analysis and risk assessments of emerging issues to identify suspected fraud, waste, and abuse and deploy our oversight and enforcement resources;

• partnering with the Department of Justice (DOJ) and the Department of Health and Human Services (HHS) on Medicare Fraud Strike Force teams and other health care fraud enforcement activities through the Health Care Fraud and Abuse Control (HCFAC) program; and

• identifying fraud, waste and abuse vulnerabilities in HHS programs and operations and advising HHS program administrators and policymakers on how to implement effective safeguards.

Federal government auditors will assist OIG with its priorities and implementing strategies. An audit of a physician or physician group is often triggered based on data that is outside of the norm of the physician group, such as utilization, medical necessity or lack of documentation as well as billing errors identified in a particular federal government study such as the Comprehensive Error Rate Testing (CERT) study (which led to CERT audits). The Recovery Audit Contractors (RACs) audits were started as part of a demonstration program under the Medicare Modernization Act of 2003 and the purpose was to identify and correct improper Medicare payments and collect overpayments. Zone Integrity Program contractors (ZPIC) audits on the other hand are intended to uncover cases of suspected fraud and take immediate action.

Regardless of the type of audit, there is a great deal of similarities among them and a physician group’s response upon notice of an audit will be similar-beginning with receipt of a document request letter. These document request letters should be taken very seriously and the physician group should immediately engage counsel. Importantly, counsel can represent the physician group through the audit, work with the agent on the scope of the audit and prepare the physician group and witnesses for the audit, which typically includes not only an inspection of records but also witness interviews. Counsel can work with the group and the agent on issues such as utilization, medical necessity and documentation.

Specific steps the physician groups should take through counsel upon receipt of an audit letter include:

• understanding the type of audit, the regulating agencies and their authority and the rules of the audit;

• identifying what the issues are for the auditor;

• engaging in an internal review of the claims and records at issue;

• working with the auditor in the furnishing of records and facility inspection;

• identifying individuals who will be interviewed and prepare them for the interviews;

• requesting claims and records to be reviewed by agent in advance;

• requesting questions for witnesses in advance;

• establishing a plan for the audit and date and time for inspection and interviews; and

• developing a process to close the audit.

It is important to understand the scope of the audit and determine whether the issues relate to overpayment due to mistakes in billing or messy recordkeeping or if it is a fraud case under the False Claims Act and develop an understanding of what the facts support. The False Claims Act prohibits a physician from submitting or causing to submit a false or fraudulent claim for payment to the government. The False Claims Act could be implicated when claims for payment are submitted on procedures not performed or based on a false certification that the physician submitting the claim has complied with all applicable laws and regulations. Where claims are submitted pursuant to an otherwise illegal arrangement (for example, an arrangement that violates the federal Anti-Kickback Statute or Stark), it is considered a false claim. Sanctions for violating the False Claims Act include treble damages, fines and administrative penalties.

Outside of the audit, physicians should be taking proactive steps toward compliance including the development and adoption of an effective compliance plan (which may serve to mitigate damages under the Federal Sentencing Guidelines). An effective compliance plan will help the physician group monitor and identify key areas of risk and develop and implement corrective action where needed, as well as assist in an organization’s credibility with a government agency in any audit.

John W. Jones, Jr., Esq., is co-chair of the Health Care Services Group, Group Purchasing and Pharmacy Practice Leader and member of the White Collar Crime Practice Group at Pepper Hamilton in Philadelphia, Pa.

Read the full article at http://www.livedigitaleditions.com/article/What+Doctors+Should+Know+About+Audits%2C+Investigations+And+Compliance/1725748/211885/article.html.

Next Page


Publication List
Using a screen reader? Click Here