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From the December ACP Hospitalist, copyright © 2007 by the American College of Physicians

OIG approves medical center's payment plan for ED coverage

A medical center that pays physicians for ED coverage will not be subject to sanctions under the federal anti-kickback statute, the Department of Health and Human Services' Office of the Inspector General recently ruled.

The medical center, which was not named in the OIG's advisory opinion, developed its payment program for on-call physicians to address problems in obtaining coverage for the ED and for follow-up inpatient care of admitted patients. Under the program, physicians in certain specialties contract with the medical center for two-year terms to take ED call and provide care to patients they admit through the ED while on call. Physicians are paid per diem rates for each day on call, with the exception of 1.5 days each month that are not reimbursed. The per diem rates vary by specialty and time of call (weekday or weekend).

The OIG examined the payment program at the medical center's request and concluded that it did not violate federal regulations for several reasons. First, participating physicians are paid fair market value for quantifiable services, not for patient referrals. Second, the medical center demonstrated that its program was developed to meet a legitimate need. Third, on-call shifts are divided evenly among participating doctors and "cherry-picking" profitable patients is unlikely because physicians must follow up on all patients they admit from the ED regardless of their financial situation.

The OIG stressed that its opinion applies only to this specific medical center and cannot be cited as support by any other group or institution. However, experts called the opinion good news, the Oct. 22/29 American Medical News reported. "What the OIG is trying to do is signal to the industry that there's nothing inherently wrong with paying for on-call coverage when the service is actually needed and a hospital can demonstrate in good faith that it is trying to get coverage for its community," one health care lawyer said.

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Boxed warnings for echo contrast agents

Boxed warnings are being added to two echocardiography contrast agents following the deaths of 11 people who used the drugs, the FDA said.

Ten deaths involved Perflutren Lipid Microsphere Injectable Suspension (Definity) and one involved Perflutren Protein-Type A Microspheres for Injection (Optison). Four of the 11 reported deaths were caused by cardiac arrest and occurred during or within 30 minutes of drug infusion, while most occurred 1 to 12 hours after administration and involved patients with severe underlying conditions. Some patients also were being treated with other medications that could have contributed to their deaths, the FDA said.

About 199 serious nonfatal reactions occurred as well, many of them either during or within minutes of administration of the drug. Medical professionals shouldn't use the drugs in patients with unstable cardiopulmonary status, including patients with unstable angina, acute myocardial infarction, respiratory failure or recent worsening congestive heart failure. The FDA also advises monitoring anyone who receives the drugs for 30 minutes after infusion.

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Medicare extends incentive program into 2008

The CMS' final physician payment rule for 2008 includes $58.9 billion in payments and incentives and extends the Physician Quality Reporting Initiative (PQRI) into next year, among other provisions.

Under the Medicare Physician Fee Schedule final rule, published in the Nov. 1 Federal Register, the PQRI would be extended with $1.35 billion in incentives provided by the Physician Assistance and Quality Initiative Fund, said a Nov. 1 CMS news release. Quality measures used in the PQRI have been endorsed by the National Quality Forum and focus on a provider's use of electronic health records and electronic prescribing.

The PQRI, which began as a voluntary reporting program last July, has allowed participating physicians to earn up to 1.5% of their total allowed charges (subject to a cap) for reporting on specific quality measures. In 2008, physicians who do not report on the PQRI measures will be allowed to participate in the program by reporting on their use of health information technology, said the CMS release.

The incentive payments are intended, in part, to counterbalance the scheduled cuts in physician fees mandated by a statutory formula tied to growth in the economy, said the CMS release. In each of the past five years, Congress has intervened to temporarily suspend the required cuts in favor of specific updates.

Some of the other provisions affecting physicians in the final rule include the following:

• The proposal to eliminate the computer-generated fax exemption from e-prescribing was modified to allow a transition period. Until Jan. 1, 2009, the exemption can be used only in instances of temporary/transient transmission failure and communication problems that would preclude the use of the NCPDP SCRIPT standard adopted in the final rule.
• CMS will continue payments for pre-admission-related services for intravenous infusion of immunoglobulin (IVIG) for an additional year to cover the cost of locating and obtaining appropriate IVIG products and resources expended to schedule infusions. Health care providers may bill for each related physician office visit when IVIG treatments are administered.
• Payments for work involved in providing anesthesia services will be increased by 32% and the value of the work component of certain physician visits to patients' homes will increase.

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New research unveiled at gastroenterology meeting

Obesity, colon cancer, NSAIDs and reflux disease were hot topics at the American College of Gastroenterology's annual scientific meeting held in Philadelphia Oct. 15 to 17. New research released at the meeting included the following:

• A study of 1,252 women who underwent colonoscopy found that obesity was the highest attributable risk factor for colorectal cancer. The researchers classified patients by age, smoking history, family history and BMI. According to the study, BMI accounted for one out of five significant lesions detected. Of the women who had colorectal neoplasia, 20% were obese and 14% were smokers. The study highlights the importance of identifying and screening these high-risk patients, said study authors.
• Using a mathematical model, researchers compared the effectiveness of initial screening polypectomies versus surveillance follow-up colonoscopy in reducing colorectal cancer mortality. The model showed a dramatic reduction in expected mortality due to the polypectomy both with and without surveillance. Based on the findings, it may be appropriate to lengthen the interval for follow-up after polyp removal to six or more years, the study authors said. ACG guidelines currently call for surveillance colonoscopy in three to five years.
• A study of 31 patients who came to the emergency department with noncardiac chest pain found that 57% had gastroesophageal reflux disease, and that more of these patients were women than men. The results suggest the role of acid reflux is overlooked as a potential factor in diagnosing and treating serious chest pain.

For more from ACG '07, see the Conference Coverage section.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated