Clip File April 1998
Clip File 4/98
April 30, 1998
6 minutes read
Clip file / Local news from the states
Each month, this page features selected short items about state health-care policy digested from newspapers around the country.
Audit reveals New York Medicaid overpaid
millions of dollars to managed care providers
ALBANY, NY-The state Department of Health overpaid managed care providers, such as Capital District Physicians Health Plan, millions of dollars in Medicaid premiums for dead or former insurance customers, a new audit reveals. Over a two-year period, from 1994 to 1996, the Health Department paid out about $7.4 million more than it should have. Ten local districts accounted for the highest amounts of overpayments, led by New York City. A Health Department spokesman said the problems have been corrected since the audit was performed.
Times Union, Albany, NY, March 24, 1998
NY Medicaid halts payments for sex-change surgery
ALBANY, NY- New York Medicaid will no longer pay for sex-change operations for poor New Yorkers, state officials announced recently. The procedure has been performed only infrequently. Since 1991, Medicaid has paid $250,000 for sex-change operations for four recipients, along with two evaluations. The last reimbursed surgery was done in 1994 to correct problems resulting from an earlier failed sex-change operation.
State health officials said there are medical arguments indicating gender reassignment remains an experimental treatment. There are also questions about the safety and cost effectiveness of the surgery as well as about the long-term safety of estrogen and testosterone use.
Patients could make a case for medical necessity, state officials say, in which case reimbursement for the procedure would be reviewed.
Times Union, Albany, NY, March 31, 1998
Report cards on hospitals and doctors may penalize providers for transferred or referred patients
PHILADELPHIA-Quality report cards on hospitals and doctors may be penalizing providers who treat patients who are transferred or referred from other providers, said a study published in the New England Journal of Medicine.
Duke University cardiologist James Jollis examined Pennsylvania's 1996 reports on the performance of hospitals and doctor groups in treating heart attack patients. Pennsylvania is one of the most advanced states in issuing quality report cards, but the researchers believe these reports are still not refined enough for public consumption.
Dr. Jollis concludes that Pennsylvania could improve the way it tallies transfers from one hospital to another. The NEJM study points out that a patient transferred to a second hospital may have gotten poor treatment at the first hospital, and that if the patient dies at the second hospital, the first hospital would get credit for successful treatment.
The researchers also believe that when heart attack patients are being treated by many doctors, only the first physician to treat a patient should be evaluated. Because early heart attack treatment is so crucial, the reports should look primarily at the first doctor to treat a patient, they claim.
The state's Health Care Cost Containment Council says it has wrestled with the issues of patients who are transferred from one hospital to another and who are treated by multiple physicians.
David Nash, Jefferson Medical College expert on medical quality and chair of the Council's advisory committee, says the reports take into account the problem of transfer patients by adjusting for anticipated death rates. (Hospitals' actual death rates were compared with anticipated death rates).
In cases where heart attack patients are treated by multiple physicians, Council leaders say it is sometimes difficult to sort out which doctor is first. The Council decided to go with the doctor or group identified as the attending physician or the physician in charge of the patient's care. The most important doctor to evaluate may not be the first, but the one who spends the most time treating the patient, they say.
Inquirer, Philadelphia, PA, April 2, 1998
FL helps low-income families obtain phone service
TALLAHASSEE, FL-About 16% of Florida families with incomes of less than $10,000 a year do not have phone service, even though there are two existing state programs to assist them with this expense.
Four state agencies recently agreed to do more to promote the programs, The Lifeline Assistance Program and Link-Up Florida. The Department of Elder Affairs, the Department of Children and Families, the Florida Public Service Commission and the Department of Labor and Employment Security agreed to promote Link-Up FLorida, which provides a $30 credit toward phone service installation, and Lifeline Assistance, which pays $10.50 toward monthly service bills.
"We have found that very, very few people participate," said Florida Public Service Commission Chairwoman Julia Johnson. "Most people who qualify don't even know this help exists."
Sun Sentinel, Fort Lauderdale, FL, April 1, 1998
Colorado physicians join forces to contract
with managed care organizations in state
DENVER, CO-Two Colorado organizations representing 1,400 physicians in multi-specialty groups hope to do away with the gatekeeper model and payment methods that they say motivate physicians to withhold care.
The two organizations are forming a partnership to share administrative functions and contract with managed care organizations.
MedSouth is a group of 600 physicians formed in February through the merger of Southcare and Health Care Continuum. Paramount is a physician association formed in 1996 when three smaller doctor groups merged. The two groups have contracted with PhyLink to provide management services.
"The real challenge is to develop management structure and information systems that tell them where their costs and quality problems are," said Ralph Pollock, a consultant with Denver-based AP Group.
Rocky Mountain News, Denver, CO, March 26, 1998
Experts debate value of performance measures
PHILADELPHIA, PA-One barrier to evaluating physicians on quality of care is that even the busiest ones don't see enough patients to allow comparison of their performance in a statistically significant way.
This is only one of many issues experts are grappling with in the quest to define quality, measure it and help consumers evaluate it, reports the Inquirer.
Arthur Leibowitz, chief medical officer at Aetna, said the public doesn't seem to be interested in one of the key measures of quality-volume. As research has shown over and over again, volume of procedures performed by doctors and hospitals is related to clinical outcome. The doctors who do the most surgery and read the most mammograms have the best results.
Paul Ellwood, the father of the HMO movement, who helped form the Foundation for Accountability (FACCT), said performance reports don't measure, "did the patient need the heart operation in the first place and was the quality of their life better or worse after they got it?"
Cheryl Damberg, director of research and quality for the Pacific Business Group on Health: notes that a provider's good or bad performance in one area doesn't tell consumers about overall performance. "If you're not going to that hospital for a bypass, what does that tell you? Maybe they have a really great obstetrics department."
While about 40% of health plans are accredited by the NCQA (National Committee for Quality Assurance), many experts say accreditation only tell you whether the pieces are in place for good care to occur. It's like checking to make sure your baker has the ingredients for a good cake and knows how to measure them correctly. You still don't know whether you'll get a good cake. The NCQA and the Joint Commission on Accreditation of Healthcare Organizations, which accredits hospitals, says that are modifying their approach to include more information on clinical quality.
While report cards are available on health plans in many markets, many of these reports are based on HEDIS data which currently is self-reported.
"I would argue that none of these report cards captures the whole picture of what quality is," said Dennis Scanlon, a Pennsylvania University researcher who recently analyzed seven such report cards.
Inquirer, Philadelphia, PA, March 29, 1998
Clip File April 1998
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