Medicolegal Issues

Medicare Modifications


Physicians who count Medicare among their payers already know the government green-lighted a 1.1% increase in Medicare Part B payments to physicians last summer. The increase was made official by the Centers for Medicare and Medicaid Services (CMS) on Oct. 30, with the release of the Medicare Physician Fee Schedule Final Rule for fiscal year 2009. The Final Rule governs what services are reimbursed by Medicare, the reimbursement levels for those services, and other rules pertaining to Medicare. Many of these changes, additions, and deletions were dictated by the Medicare Improvements for Patients and Providers Act, or MIPPA. (See “MIPPA Matters,” December 2008, p. 18.)

The 2009 Final Rule not only makes official the short-term, 1.1% payment increase, it also marks significant increases in payments for inpatient evaluation and management services, higher bonuses for participation in the Physician Quality Reporting Initiative (PQRI), and new policies to help direct the future of healthcare.

Here is a look at a few of the key aspects of the Final Rule, of which you may not be aware:

Transparent Physicians

In a continued effort to make healthcare transparent, CMS will begin posting the names of physicians who successfully report through the 2009 PQRI on a physician compare Web site in 2010. (2007 and 2008 PQRI participants will not be included.) Just as the Hospital Compare site enables consumers to view data on facilities, this site will allow consumers to view data reported by individual doctors.

Although consumers may be interested in checking for information on their primary care physician, it is unlikely inpatients will check the site before agreeing to see a specific hospitalist. However, the Physician Compare site will have some impact on hospital medicine. “I think this is the beginning of physicians’ commitment to greater transparency,” says Eric Siegal, MD, chair of SHM’s Public Policy Committee. “In a very broad sense, physicians who agree to be listed on the Physician Compare site very clearly value transparency and quality of care. Their inclusion could be seen as a differentiator, though a small one.”

Another factor to consider regarding transparency: “Physician Compare is not just about patients,” Dr. Siegal points out. “Third-party payers will look at this, as well. If they’re looking for someone to help take care of their patients, this data might sway them in their decision.”

Public Policy Points


A new Web site sponsored by the Agency for Healthcare Research and Quality (AHRQ) offers a public repository for evidence-based quality measures and measure sets. The National Quality Measures Clearinghouse (NQMC) site ( is designed to provide healthcare professionals with “an accessible mechanism for obtaining detailed information on quality measures, and to further their dissemination, implementation, and use in order to inform healthcare decisions.” The NQMC includes a comparison tool for different measures, summaries of how the measures were developed, and commentary from the site’s editorial board. The database includes measure sets from federal agencies, including the Administration on Aging, AHRQ, the Centers for Disease Control and Prevention, Centers for Medicare and Medicaid Services (CMS), the Office of Public Health and Science, the National Institutes of Health and more.


CMS is not the only payer pushing for e-prescribing; doctors participating in Blue Cross and Blue Shield of Massachusetts’ physician incentive programs will be required to prescribe medication electronically beginning in 2011. Physicians will be allowed to request financial assistance to help cover e-prescribing start-up costs, including equipment and training. According to the insurer, 99% of primary care physicians in BCBS Massachusetts’ HMO Blue network and 78% of specialists currently participate in the incentive program. The company estimates e-prescribing saved members roughly $800,000 in 2006 by identifying less-costly prescription alternatives.


The U.S. does not measure up when it comes to caring for chronically ill patients, according to a new study from the Commonwealth Fund. In a survey of 7,500 chronically ill patients in Australia, Canada, France, Germany, the Netherlands, New Zealand, the United Kingdom, and the U.S., patients in the U.S. are far more likely to go without healthcare because of costs than patients in the other countries. U.S. patients also saw higher rates of medical errors, coordination problems, and steep out-of-pocket costs.

Telehealth and Inpatients

Medicare already reimburses for certain exchanges of medical information from off-site physicians or vendors via interactive electronic communications, also known as telehealth or telemedicine services. Under the 2009 Final Rule, CMS will create a new series of Healthcare Common Procedure Coding System (HCPCS) codes for follow-up inpatient telehealth consultations, allowing practitioners to bill for follow-up inpatient consultations delivered via telehealth.

These codes are intended for use by physicians or non-physician providers when an inpatient consultation is requested from an appropriate source, such as the patient’s attending physician. CMS emphasizes the codes are not intended for use in billing for the ongoing evaluation and management of a hospital inpatient.

E-prescribe Out of Reach

Much attention has been given to a new Medicare program, which promotes the widespread adoption of electronic prescribing (e-prescribing). Physicians who successfully participate in CMS’ Electronic Prescribing Incentive Program will earn an extra bonus; however, the program was designed for primary care programs and hospitalists are unlikely to be able to take advantage of this.

“We don’t even know if hospitalists will be able to participate,” Dr. Siegal explains. The only way a hospitalist can take part in the e-prescribing initiative is if the hospital already has an acceptable system. However, Dr. Siegal warns, “If you create a mandate requiring a system for medication reconciliation at discharge, and then require another, separate system for e-prescribing, you’ve got problems. The primary driver should be that the hospital’s system supports both. And as far as we can tell, most hospital systems don’t do this.”

In August, SHM and the American College of Emergency Physicians conducted a teleconference with CMS to voice concerns with the e-prescribe initiative. “What we wanted was an exception,” Dr. Siegal says. SHM’s concern: When CMS stops rewarding physicians for e-prescribing and begins to penalize those who don’t—currently scheduled for 2013—hospitalists who can’t participate will be penalized through their Medicare payments. The outcome of the meeting, Dr. Siegal says, is “CMS turned around and said ‘either you can participate or you can’t.’ But at least they are considering our points; they seem to understand them.”

The good news is there is time to work the problem out, “At the moment, while e-prescribing is all bonus and no penalty, there’s no urgency to address it,” Dr. Siegal says.

Patient Safety

The Final Rule also includes improvements to PQRI, which allows eligible professionals to report on 153 quality measures. Physicians who successfully report on cases during 2009 will be able to earn an incentive payment, which has been increased to 2% (up from 1.5% in 2008), of their total allowed charges for covered professional services.

“I hope that more hospitalists will get on board with this,” Dr. Siegal says. He believes PQRI will be around for a while, and any hospital medicine group waiting to see if it is worth investing in the program can safely do so. “My feeling is that there’s growing bi-partisan support for something like this. I think it’s here to stay,” Dr. Siegal says.

SHM’s Opinion Counts

One reason the Final Rule is especially hospitalist-friendly is because SHM submitted extensive comment on CMS’s proposals in August. “SHM had a fair amount to say, and there are things in the rule that dovetail with our comments,” Dr. Siegal explains. “Part of the challenge is picking which battles to fight; there is a lot covered in this rule. We ended up focusing on areas that were really important to us, and on items where we thought we had a unique voice where nobody else was going to articulate.”

The Final Rule is available at under “CMS-1403-FC.” Fact sheets covering major provisions of the Final Rule are available at fact_sheets.asp. TH

Jane Jerrard is a medical writer based in Chicago.

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