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Policies Protect Against Compliance Failures

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              CARDIOLOGY PRACTICE
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A PRACTICAL RESOURCE    TO   SUCCEED     IN   HEALTH CARE                            March 15, 2002



CONTENTS                 Policies Protect Against
Features                 Compliance Failures
                                 hysicians concerned about a       ed case could exceed $750,000,
Commentary
Automating Patient
History Boosts
Physician
                         P       compliance audit may want
                                 to consider new insurance
                         policies that indemnify physicians
                                                                   experts say.
                                                                      A policy providing at least $1 mil-
                                                                   lion in coverage may be needed if a
                         against losses resulting from a gov-      physician is audited, says Shepherd.
Productivity       3     ernment audit and an investigation        This amount should be enough for a
                         for erroneous billings, allegations of    physician to hire a competent legal
                         false claims, or charges of fraud.        defense team and pay most costs in a
Strategy                    The risks physicians face resulting    case involving lengthy litigation,
Study Shows              from a federal audit of their billing     experts say.
Angioplasty Outcomes     practices are significant, says Stephen      The typical malpractice policy,
Depend on Procedure      Shepherd, vice president of the med-      which most physicians have, provides
Volume              8    ical insurance division of Geo. F.        coverage of only $25,000 to $50,000
                         Brown & Sons Inc., an insurance           in the event of an audit. Most of these
                         consultancy, in Chicago. Brown            policies would be inadequate for pro-
Interview                manages the compliance assurance          viding coverage in a fraud case. In
Surgeon Says             program (CAP), which provides cov-        fact, some malpractice policies pro-
Collaboration            erage in the event of a loss. Often,      vide no coverage in fraud cases.
Helps Physicians,        the losses from risks physicians face        “I wouldn’t be surprised if a physi-
Hospitals Succeed 13     could exceed what many practices          cian’s malpractice carrier declined to
                         could pay, so an insurance policy that    offer coverage for that physician if he
                         protects against such losses would be     or she becomes the target of a gov-
Departments              a worthwhile investment.                  ernmental investigation for alleged
                                                                   improper coding or billing practices,”
                         Taking Cover                              says Feltes. “In that scenario, the
Editorial                The cost of defending a physician in      physician must absorb all legal
Defined Contribution     a fraud case could range from             expenses, which could mount up
Plans Create             $100,000 to more than $1 million,         quickly and significantly, especially if
Options             2    experts say. “In addition to paying       the physician is unable to reach a set-
                         legal fees for discovery, preparation,    tlement and is forced to litigate.”
                         and court room appearances, the              For a policy that provides compe-
Practice Management      physician also must pay an expert to      tent coverage, a practice could pay
Groups Seek to           review charts and testify at court,”      between $1,500 and $3,000 per physi-
Improve Operations 6     says Joseph Feltes, a senior health       cian per year, and that coverage can
                         attorney with Buckingham, Doolittle       differ among policies, Shepherd says.
                         & Burroughs LLP, in Cleveland.            For example, attorneys working on
                         “The total litigation expense package     behalf of the physician could be paid
                         to defend a civil false claims action,    directly from the policy; if not, the
                         for example, could exceed $300,000.”      physician would have to pay the attor-
                         What’s more, legal fees in a protract-    neys and wait for reimbursement.
                                                                                     (Continued on page 10)
   STRATEGY


Study Shows Angioplasty Outcomes
Depend on Procedure Volume
           any studies of cardiac pro-     tals and 75 total procedures, but pri-   going primary and elective angioplas-

M          cedures have demonstrated
           a positive relationship
between the volume of procedures
                                           mary angioplasties may comprise
                                           only a small fraction of the total PCI
                                           procedures performed by any one
                                                                                    ty in 32 hospitals in New York.
                                                                                       To cull out the primary angioplasty
                                                                                    procedures, researchers selected cases
performed by a physician or at an          physician or hospital.                   involving patients experiencing a
institution and the outcomes of those         “Primary angioplasties are more       heart attack that had begun within 23
procedures. Such findings have             complex than elective procedures,”       hours of the procedure. “We also
prompted the American College of           notes Brown. “The patients are typi-     eliminated patients who had received
Cardiology (ACC) in Bethesda, Md.,         cally unstable, they are experiencing    thrombolytic therapy within the prior
and the American Heart Association         arrhythmias and hemodynamic              week,” Brown says. “We wanted to
(AHA) in Dallas to issue minimum           instability, and they may be going       ‘clean’ the data of patients who might
volume guidelines for percutaneous         into congestive heart failure or         have been undergoing ‘rescue’ angio-
coronary interventions (PCIs), such        shock.” Physicians with these cases      plasty or angioplasty after failed
as angioplasty, coronary stent proce-      must make medication and other           thrombolysis.” Of the total number of
dures, direct coronary atherectomy,        decisions that are not part of routine   angioplasties, 1,342 were designated
and laser therapy.                         angioplasty cases, which are fairly      as primary angioplasties.
   A new study published in Circula-       straightforward procedures, he adds.
tion demonstrates that this relation-         The analysis reported in the Oct.     Volume Stratification
ship also holds for primary angioplas-     30 issue of the journal indicated that   The researchers divided physicians
ty, and is especially strong with regard   primary angioplasty patients with the    and hospitals into volume terciles.
to physician procedure volume.             best outcomes are those treated by       Physicians and hospitals in the low-
                                           high-volume operators at high-vol-       volume tercile performed one to two
Atypical Patients                          ume hospitals. “Our findings indicate    and one to 17 procedures per year,
“Patients who present with acute           that there is an interaction between     respectively. Physicians and hospitals
myocardial infarction have a much          hospital and physician volume that       in the middle tercile performed three
higher acuity of illness than those        results in the best outcomes,” says      to 10 and 18 to 56 procedures per
who receive elective angioplasties,”       Brown. “When we looked at hospital       year, respectively. Physicians and
says David L. Brown, MD, an inter-         and physician volume independently,      hospitals in the high-volume tercile
ventional cardiologist and chief of        this volume-outcome link is more         performed 11 or more and 57 or more
clinical cardiology at the Montefiore      strongly influenced by physician vol-    procedures per year, respectively. The
Medical Center in the Bronx, N.Y.          ume than hospital volume.”               researchers designated in-hospital
“Given that elective angioplasty and          The researchers used data from the    mortality as the outcome measure.
primary angioplasty require different      Coronary Angioplasty Reporting Sys-        After adjusting the data for differ-
physician skill sets, we were interest-    tem of the New York State Depart-        ences in demographics and comor-
ed in whether the physician expertise      ment of Health, which requires that      bidity, the researchers found that the
obtained by handling the higher risk       physicians submit data on every          mortality rate among patients treated
primary angioplasty cases would lead       angioplasty performed in the state.      by high-volume physicians in high-
to better outcomes.” ACC/AHA               The 1995 registry—the most recent        volume institutions was 3.7%, com-
guidelines recommend an annual             information available—included data      pared with 7.6% for patients treated
minimum of 400 total PCIs for hospi-       on more than 22,000 patients under-      by low-volume physicians in low-vol-
                                                                                                      (Continued on page 9)

  The mortality rate among patients treated by high-volume physicians
  in high-volume institutions was 3.7%, compared with 7.6% for patients
  treated by low-volume physicians in low-volume hospitals.


8 Practice Options/March 15, 2002
STRATEGY
(Continued from page 8)
ume hospitals.                              tive correlation between volume and        angioplasties.”
   Interestingly, large numbers of pro-     outcomes is a representation of physi-        Another issue is that the research
cedures were not required before a          cian judgment, which is reflected in       has almost uniformly used annual
quality difference was detectable,          how physicians care for individual         physician volumes in analyses, rather
Brown reports. “The high-volume             patients based on the sum of their         than cumulative experience over
physicians performed only one prima-        experience,” says Paul McGrath,            time. “One thing that has always
ry angioplasty a month, while the           MD. “Regarding institutional vol-          bothered me about volume-outcome
high-volume hospitals performed only        ume, the volume-outcome relation-          research is that the studies look at a
one a week,” he says. “Still, physicians    ship is probably a marker of how           physician’s or a hospital’s volume for a
and hospitals that perform less than        effective the hospital’s systems and       single year and label it ‘high volume’
that probably do not have adequate          processes are. In institutions with        or ‘low volume,’” Brown says. “But
experience to deal with all the com-        greater angioplasty volume, the hos-       wouldn’t a physician who has been
plications that may occur in these          pital technicians and nursing staff        performing 50 angioplasties a year for
very unstable patients.”                    will know how to work most effec-          the last 10 years improve over time?

Volume and Outcomes
Brown also emphasizes that physician          “The positive correlation between volume
volume seems to be a more important           and outcomes is a representation of physi-
factor than hospital volume in influ-
encing outcomes. “The skill of the            cian judgment.”
particular physician outweighs hospi-                   —Paul McGrath, MD, Maine Medical Center
tal factors,” he observes. The mortali-
ty rate of patients treated by high-vol-
ume physicians was 3.8% compared            tively and can implement evidence-         And would a physician right out of
with 7.1% for those treated by low-         based clinical protocols. Taken            training who performs 100 cases his
volume physicians. Hospital volume          together, all of these factors feed into   first year really be better at the proce-
differences generated a smaller mor-        better quality and better survival         dure than the first physician?
tality differential: 4.0% in high-vol-      rates.” McGrath is a practicing cardi-     Experience is cumulative, something
ume hospitals compared with 5.8% in         ologist at Maine Medical Center in         that has not been taken into account
low-volume hospitals. Performance of        Portland and a research associate at       in these single-year studies.”
primary angioplasty by a high-volume        the medical center’s Center for               Researchers found the age of the
physician would result in saving 33         Outcomes Research and Evaluation.          data somewhat disconcerting, Brown
lives per 1,000 patients treated, while                                                adds, but he does not believe the
18 lives per 1,000 treated would be         Cumulative Experience                      results of the study would be signifi-
saved if all were treated at a high-vol-    The research may reveal the need for       cantly different if more recent data
ume hospital.                               further clarification of the ACC/AHA       were used.
   Offering a hypothesis about why          volume recommendations, which are
physician volume heavily influences         based on total (elective and primary)      Practice Implications
outcomes, Brown says, “The success          angioplasties and may obscure impor-       The implications of Brown’s research
of the procedure itself seems to drive      tant differences in the physician skills   and other studies have been “very
the ultimate in-hospital outcome of a       necessary for performing these proce-      touchy politically,” Brown states.
patient who undergoes primary angio-        dures. “The ACC/AHA guideline rec-         “Some in the industry have used
plasty after acute myocardial infarc-       ommends a minimum volume of 75             these kinds of data to posit that there
tion. If patients leave the cath lab in     annual physician procedures,” Brown        should be heart attack centers, just
good shape, the hospital can probably       says. “But this number probably            like there are trauma centers,” he
care for them during their recovery         reflects largely elective procedures.      says. Some people believe that heart
without too much difficulty.”               However, an interventional cardiolo-       attacks should be treated in a few des-
   The main factors driving the vol-        gist who performs only 50 angioplasties    ignated centers, where the expertise
ume-outcome relationship in angio-          a year, of which 40 are primary angio-     at both the hospital level and the
plasty are not defined by the study,        plasties, will have better primary         physician level could be concentrat-
but are likely to reflect that physicians   angioplasty outcomes than the physi-       ed. But heart attack patients are more
simply improve with experience.             cian who performs 100 angioplasties a      common than trauma patients, and
   “On the cardiologist side, the posi-     year, of which only 10 are primary         many physicians practicing in low-
                                                                                                         (Continued on page 12)


                                                                                          Practice Options/March 15, 2002 9
   STRATEGY

(Continued from page 9)
volume environments have good                   The research may reveal the need for
results. Creating heart attack centers
would be a difficult, and possibly
                                                further clarification of the ACC/AHA
unfair, proposition.”                           volume recommendations.
   Still, studies on the volume-out-
come link can help physicians
improve their practices, Brown                offering high quality to their patients.”   forming primary angioplasty. The
believes. “Analyzing and publicizing          Hirshfeld is a practicing intervention-     researchers found that at centers per-
these data can help cardiologists,” he        al cardiologist, director of the cardiac    forming relatively few primary angio-
says. “Low-volume operators never             catheterization laboratory at the           plasties, mortality rates following a
think their outcomes are poorer than          University of Pennsylvania Medical          heart attack were similar for primary
those of a higher volume colleague.           Center, and professor of medicine at        angioplasty and thrombolytic therapy.
Volume-outcome studies can encour-            the University of Pennsylvania              However, at the more experienced
age physicians to analyze their out-          School of Medicine in Philadelphia.         centers, the mortality rate of patients
comes more carefully. After such              He also chairs the ACC’s Cardiology         who underwent primary angioplasty
analysis, cardiology groups that per-         Cardiac Catheterization and Inter-          was significantly lower than the mor-
form primary angioplasties may want           vention Committee, and authored the         tality rate of those who had received
to concentrate the procedures among           1998 guidelines on recommended              thrombolytic therapy. The study was
a few interventionalists. While vol-          angioplasty volumes.                        published in JAMA, Dec. 27, 2000.
ume-outcome research may not yield               Another implication relates to the          “Outcomes at low-volume hospi-
policy changes, we can hope for               selection of hospitals in which physi-      tals are equivalent for primary angio-
greater self-examination and self-            cians operate. “Physicians who prac-        plasty and thrombolytic therapy,”
education among cardiologists.”               tice in urban centers, which likely         Brown observes. “All things being
   Some cardiology practices have             include several hospitals, may seek to      equal, patients may be better off get-
developed a degree of subspecializa-          practice in a high-volume hospital,”        ting thrombolysis than undergoing a
tion, McGrath explains. In these              says Brown. “For physicians who have        procedure by a team and a physician
practices, a group’s angioplasty proce-       a choice, the data indicate that out-       who are not experienced.”
dures are triaged to a core set of car-       comes will be better if patients are           McGrath adds that, as data on the
diologists, he says. “However, the            treated at a high-volume institution.”      volume-outcome relationship in
practice in other regions around the          Physicians may also want to analyze         angioplasty are collected, referral pat-
country may reflect a high number of          the outcomes of procedures performed        terns might begin to shift based on
cardiologists in a single group, all of       at different hospitals.                     volume. At the same time, managed
whom perform angioplasty proce-                                                           care organizations are becoming
dures at relatively lower volumes             Referral Patterns                           more likely to contract with high-
each,” he adds. “These practices may          “Physicians with less experience in         volume providers. “Contracting
be able to improve their quality of           performing angioplasty generate bet-        based on volume is occurring around
care by tracking outcomes for each            ter outcomes when they perform pro-         the country, as managed care organi-
physician, determining who has the            cedures in a large, experienced insti-      zations and employer groups have
best outcomes, and then designating           tution,” Hirshfeld says. “This differ-      begun to channel patients to pre-
those clinicians to be the high-vol-          ence likely exists because, in a high-      ferred providers and hospitals,”
ume providers of angioplasty.”                volume institution, they have access        McGrath says. “Such channeling is
   Overall, study data supporting the         to support resources to assist them if      receiving a groundswell of support
volume-outcome relationship in                they encounter a complication or a          from providers as well as payers.
angioplasty have had only a limited           technically challenging situation.”         Given the strong evidence support-
effect on actual practice. “It is difficult     Physicians who practice in low-vol-       ing the positive relationship between
for a low-volume practitioner to              ume hospitals, however, might               volume and outcomes, I believe we
accept the fact that his or her out-          choose to offer thrombolytic therapy        will see more contracting based on
comes may not be as good as those of          instead of angioplasty as an initial        volume as the years unfold.”
a high-volume physician,” confirms            measure. A research team led by             —Reported and written by Deborah J.
John W. Hirshfeld, MD. “In their              David J. Magid, MD, MPH, com-               Neveleff, in North Potomac, Md. More infor-
hearts, low-volume practitioners sim-         pared both therapies at hospitals with      mation on physician practice strategies is avail-
ply do not believe that they are not          different levels of experience in per-      able on our Web site (see page 16).



12 Practice Options/March 15, 2002
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A PRACTICAL RESOURCE            TO   SUCCEED        IN    HEALTH CARE                                            March 15, 2002

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