Policy 2.0 : Discussion List - All Communities

Medicare NPI registry shows confidential information

info@hopestreetgroup.org — Wed, 25 Aug 2010 03:44:09 GMT

The NPI registry, also called the National Provider Identification registry, is a digital database of all Medicare providers. In a system that handles hundreds of millions of pieces of confidential information, though, there are weaknesses. The newest NPI database discloses extra details that then opens the door for Medicare fraud. Post resource: Medicare NPI registry reveals confidential info by Personal Money Store

The registry of NPI

The Medicare system is a very complicated bureaucratic maze that depends on the NPI registry, National Supplier Clearinghouse numbers and Medicare Administrative Contractors. The NPI Registry database is called the National Plan and Provider Enumeration System. The NPPES was intended to simplify the payment of Medicare claims. In the end, though, the NPPES also gives out the National Supplier Clearinghouse number of a provider, which opens up both patient and provider details that should be confidential.

Registry info for NPI

The National Provider Identification registry works with various other cogs within the Medicare system. With just the NSC number and a patient's claim number, anybody can access details, a patient's diagnosis and procedures, and more. The new NPI registry opens up the bones of the Medicare payment system to possible exploitation.

NPI registry difficulties being fixed

Contacting the three major arms of the Medicare payment system to ask about the NPI registry problem resulted in being given the runaround, as reported by Home Care Magazine. The suggestion of deleting the NPI information from the database means that a provider might not get paid. In other words, this means that providers have to decide between being paid by Medicare for services they provide, or protecting the personal details of the doctors and patients. Though various solutions can be very easily coded by dedicated programmers and have been suggested, the NPI registry has not said they will be implementing any of them.

Discover more information here:

Home Care Magazine

homecaremag.com/news/nsc-numbers-revealed-npi-registry/

Concensus on Question 1. Is the Impact on Reward Systems Appropriate? Why or Why Not?

info@hopestreetgroup.org — Sun, 23 Aug 2009 23:58:22 GMT

The impact on reward systems is not appropriate. Rarely is there any impact on the reward system as most of the reward systems are tied to degrees earned and years in the system.

Would you allow your doctor to conduct follow up appointments on the phone?

info@hopestreetgroup.org — Mon, 11 Jan 2010 20:03:35 GMT

With the current primary care shortage, many people are evaluating new approaches to providing care such as with the increased use of telemedicine. Telemedicine is described as the application of clinical medicine where medical information is transferred through the phone or the internet and sometimes other networks for the purposes of consulting, and sometimes remote medical procedures or examinations. Accordinging to the Wikipedia page, "Telemedicine may be as simple as two health professionals discussing a case over the phone or as complex as using satellite technology and video-conferencing equipment to conduct a real-time consultation between medical specialists in two different countries."

With that in mind, would you allow your doctor to conduct a follow up appointment over the phone? It could save time for over-burdened primary care physicans and save you the cost of an office co-payment, but would you get the same care on the phone as you would in an office? Share your thoughts with the rest of the policy 2.0 community by logging in or replying.

Primary Care office start ups

info@hopestreetgroup.org — Fri, 13 Aug 2010 15:51:24 GMT

Hello,

There is movement in the US toward non physician providers taking the role of primary care providers e.g. PA and NP...and even Physical Therapists.

For entrepreneurs looking at starting independent clinics whose main provider is a mid level person or PT and given the current healthcare reform climate -

what is the financial prognosis in this kind of venture?

Thanks,

Tom Plamondon PA-C, PT

Managing Partner

Northview Health Solutions

989 670 1599

Barriers To Primary Care Innovation Regarding Training: Too Many Stages in the Path

info@hopestreetgroup.org — Fri, 06 Aug 2010 22:59:04 GMT

Too many steps, Too many separations, Too many leaks in the pipeline, Too little yield across the segments, Too many accreditations, Too many funding sources, Too many determining training curricula, and very few focused on basic health access

The last rural workforce meeting of AAMC in 1990 broke up when a Dean from SD Robert Taylor suggested primary care coordination such as combining primary care. Much of his presentation and work failed to notice the talk about unifying accreditation and funding and responsibility, but as is typical when turf is discussed, the meeting went south. Immediately the talk focused on the various primary care types instead of rural workforce focus. At this meeting those at the previous meeting 17 years before noted that nothing had been done and those at the previous meeting 17 years before noted the same. Of note is that it has been 20 years now and counting, not that meeting did much anyway.

http://www.ruralmedicaleducation.org/images/Retention4.GIF These four graphics indicate that we have added lots of PC grads, but get decreased PC delivery per grad

We keep adding steps, lengthening the time in academic centers, and then claim more primary care when we have less. also note that the substantial reforms of the 1990s, barely made a dent in primary care delivery increases to stop the steady declines of past decades.

As a chemistry major I was not very good when there were multiple steps in the synthesis. With each new reaction my product yield got smaller and smaller. I was a much better teacher than I was a chemist.

The teaching pathways to primary care workforce are a real problem for primary care workforce.

Market forces training has totally failed with perhaps 10 - 20% of MD, DO, NP, and PA graduates entering primary care.

With some public assistance and some responsibility for the yield, the "quality" goes up as measured by 20 - 30% remaining in primary care.

But the problem is that the yield is far too low.

Historical standards - the Class of 1960 AMA Longitudinal study tracked graduates of primary care training and the survival curve indicated 50% remaining in primary care at retirement. The overall primary care was 71% for an entire career. Also the volume of primary care delivered was likely to be higher for a number of reasons. Activity in practice was also higher (male, more hours).

What do we have now - FM at about 75 - 80% for a career, PD beginning at less than 50%, PA beginning at 28% in primary care, NP - hard to tell as entry data is poor but about 33% would be a starting point for the first decade with lower in the last 17 years. Also all sources have increasing administrative positions with even higher levels in NP.

The problem is that there are too many stages in the pathway from entry into higher education until entry into practice.

And we have added the need for retention at every year after graduation for IM, NP, and PA - the most flexible primary care forms.

What would work?

Age 18 entry into basic health access primary care training
2 years of premed specific to health access preparation while working in a health access location
6 years of specific health access training similar to medical school and a primary care residency, although more specific to basic health access
10 years of an instate obligation for primary care delivery with 5 years in a most needed location determined by the state's primary care leadership and a second 5 years somewhere other than where primary care is sufficient

Fewer Steps

One entry point
One opt out point in the first two years for those not matching up (their call or ours)
One exit point at age 36 after providing more most needed health access than any current graduate of any source and school, and after providing the same primary care as a PD graduate or an FM non-citizen IMG, twice the primary care of an average US origin IM graduate, three to four times a current NP or PA graduate, and 5 times the non-citizen IM IMG graduate

And after the ten year obligation is over there are 28 - 30 years remaining in their career also likely to be health access after 18 years of selection, training, and dedication to such a career.

Longer years in a career
Primary care and most needed workforce during training
Nearly twice the primary care of an average US primary care graduate (only 6 and decreasing to 4 SPC years) during the obligation and all instate
Then much more remaining

But of course there are barriers as we separate preparation, admission, initial training, graduate training, short term obligation (if any), and subsequent voluntary choice to remain in primary care at all (each year) or to remain in most needed health access (each year) and the tendency over a career is to move steadily away from primary care and most needed health access.

And these steps and the accreditation process, and the funding for training, and the funding for primary care support - are all determined by panels that are 70% or greater hospital and specialty and academic.

Even those who do call for responsibility, accountability, and illustrate health access models make no headway as Butler found out (by permission of Academic Medicine) at http://www.ruralmedicaleducation.org/season_of_accountability.htm

Also the most productive years are dedicated to primary care delivery and health access as compared to primary care forms that enter age 38 and later.

Bob Bowman www.basichealthaccess.org

AACOM had a nice review by Eskew regarding the barriers to what we need http://www.aacom.org/events/annualmtg/past/2010/Documents/Eskew_Finding-a-Faster-Route.pdf

The info on Accelerated FM programs is not accurate My site has data representative of the national output, and discussions of the termination of this model that involve failure of primary care innovation support http://www.ruralmedicaleducation.org/short_and_sweet_accelerated.htm 150 grads were tracked by me from eleven programs, 3 years med school and 3 years FM residency, 40% rural (FM is 24%, US docs 10%), 19% high poverty (FM 15%, US docs 7%) - over 50% in various underserved areas at any given time 54% were four or more years older at graduation - maturation, previous life and health experience all committed to FM one year early indicating the impact of early focus on FM the Nebraska track continued at 4 to 5 per year and had 70% remaining instate in rural locations, the same as the Nebraska RTT programs, other Nebraska FM grads have about 40 - 50% rural but not the same instate rate.

The WHO Report on Rural and Remote Health also mistakenly noted that controls for origins, training, and career choices were lacking in workforce studies

Here is what various origins plus FM types of training accomplish in outcomes for the 1997 - 2003 FM grads

Birth Location	Rural % by Accelerated FM Graduate	Rural % by Usual FM Graduate
Urban	48.8%	15.7%
Large Rural	42.1%	35.5%
Medium Rural	63.6%	33.7%
Isolated Rural	87.5%	33.6%

		Urban Less than 75 docs, Poverty 19%	Rural, Less than 75 docs, Poverty 19%	All Rural by RUCA	Rural Less than 75 docs at zip	Major Medical Center 75+ docs at zip	Teaching Location (likely higher now)
Not Accelerated	20815	5.1%	6.3%	20.5%	17.3%	50.6%	3.2%
Accelerated	136	0.7%	14.0%	44.1%	42.6%	35.3%	5.9%
Control in Same Residency	587	3.1%	10.4%	27.9%	25.4%	46.8%	4.4%
Control in Same Med Sch and Residency	249	7.2%	8.8%	32.1%	26.5%	45.0%	3.2%
Same Med School Diff Residency	1026	4.2%	8.5%	28.1%	23.1%	46.9%	2.5%
	22813	5.0%	6.6%	21.3%	18.1%	50.1%	3.2%

Should people be paid to take medication?

info@hopestreetgroup.org — Wed, 16 Jun 2010 13:43:40 GMT

A recent New York Times article profiles monetary incentive programs designed to increase prescription medication adherence. Methods range from electronic lotteries, discounted copayments and monthly adherence payments for patients, through to paying pharmacists to help patients with adherence and paying doctors to prescribe medications. There is evidence that high levels of medication adherence can reduce hospitalization and lower all-cause medical costs - but is paying people to take their medication the right way to go?

What Would You Ask A Major Player in Primary Care Reform?

info@hopestreetgroup.org — Tue, 13 Apr 2010 20:08:38 GMT

On May 3, 2010 we will be hosting our first Bipartisan Working Group Dinner on Reinventing Primary Care. This dinner will be a “roll-your-sleeves-up” type session that brings to bear the tremendous knowledge base of our advisers to problem solve with project team leaders and devise credible paths of implementation for the Reinventing Primary Care Project.

We’re opening up an opportunity to all of our Policy 2.0 members to post a question that our Executive Director, Monique Nadeau will pose to the group. With that in mind, what would you ask a major player in health care reform about Primary Care?

You post, we'll ask, and then repost the responses.

To Get You Started:

- Log In/Register to Post Your Question

- Post Your Question

- Example Questions

Has lack of access to a primary care practitioner ever led to a negative health outcome for you or a member of your family? Share your story.

info@hopestreetgroup.org — Wed, 14 Oct 2009 20:05:09 GMT

Share your stories with the Policy 2.0 community about an experience where lack of access to a primary care practitioner has led to a negative health outcome for you or a member of your family.

Why are 2008 Projections of Primary Care Workforce indicating substantial increases when the reality is decreases in primary care?

info@hopestreetgroup.org — Wed, 21 Jul 2010 22:38:59 GMT

How is it possible for HRSA Primary Care projects in 2008 to indicate an increase in family medicine to 145,000 when family medicine is steady state with about 2500 entering and remaining in primary care each class year since before 1980 with about the same 2500 departing primary care each year? Family medicine has reached a maximum of 100,000 to 110,000.

Pediatrics is also steady state with 1400 entering and leaving. More graduates cannot help primary care as this has only resulted in more specializing. Pediatricians have not demonstrated the distribution to rural and underserved populations (or zip codes with fewer physicians, less hospital access) and this has resulted in saturations of pediatric primary care. More graduates only bounce.

HRSA has internal medicine increasing to 155,000. Internal medicine is declining to less than 50,000 by 2030 as less than 1500 are entering and remaining in primary care each year. Actually office based internal medicine in the Masterfile reached about 80,000, so the problem may be overestimates to start with.

NP and PA workforce is also relatively steady. Increased graduates has been offset by decreases in primary care retentino in all class years with the newest class years (as in PAs) indicating lower primary care to come (and those responding to surveys may well have higher percentages in primary care than reality as noted by AAPA)

Projections are nice, but the reality must be calculated over 30 - 35 year periods, not rosy first career choices or first practice choices, transitions, and obligations.

How can viable workforce discussions proceed if major association and government reports are in error?

What do you think is the biggest barrier to innovation in primary care?

info@hopestreetgroup.org — Wed, 16 Jun 2010 12:59:17 GMT

It is possible to point to a number of barriers that limit the spread of innovation in primary care (see some examples below). What do you think is the biggest barrier to innovation in primary care? What do you think about the examples listed below? What would you add or remove from this list?

Examples of barriers to innovation in primary care

Variations across states in scope of practice regulations
Reimbursement rules and lower earnings overall limit the attractiveness of primary care specialties
Current training and practice in silos does not support team-based work
Malpractice insurance rules discourage part-time work, especially for retirees
Inadequate access/utilization of health IT – telemedicine, electronic communication, EHRs – restricts access in rural/underserved areas
Administrative burden of care coordination
Design of new payment models is complex
Payment models (such as pay-for-performance) may incentivize shedding of sickest patients, or penalize those providers with more chronic & complex patients
Lack of data analysis capacity

Barriers to the spread of particular models:
Retail clinics – concern about fragmentation of care coordination, concern about loss of revenue by other providers, lack of shared electronic record with PCPs
Accountable Care Organizations – limited number of demonstration projects – new and unproven payment mechanisms, lack of consistent specifications, antitrust: perceived risk of collusion in the guise of care coordination, loss of revenue from emergency presentations.
Patient Centered Medical Homes – lack of clarity about essential features to ensure quality outcomes, sustainability of savings unproven – quality-funding link not built into the model, access to well-trained care coordinators.

Correcting the Mismatch Between M&M and Health Worker Distribution

info@hopestreetgroup.org — Thu, 24 Jun 2010 17:30:03 GMT

There is currently a mismatch between the location of preventable morbidity and mortality in the US and the location of primary health care workers. How can we correct this mismatch in the short term and long term?