Practice Beat

Practice Beat

Accreditation: Now it's PPOs' turn to pass muster on quality

The National Committee for Quality Assurance, which has been accreditingHMOs since 1991, expects to launch a full-fledged PPO accreditation programby next July. The initiative will include on-site reviews of appeal procedures,provider evaluation processes, medical-review systems, and quality improvementefforts.

The initial accreditation phase, expected to begin later this year, willfocus on PPO members' experiences with their plan and its primary care physiciansand specialists.

Docket Watch: New Jersey judges set the record straight on informedconsent

A doctor has a duty to explain the risks and likely outcomes of all medicallyreasonable treatment alternatives, including those the physician doesn'trecommend, the New Jersey Supreme Court has ruled. By not discussing alternatives,the court noted, the physician "effectively makes the choice for thepatient."

The ruling stems from the case of an octogenarian who had fractured herright hip. After evaluating the patient's history, condition, and X-rays,an orthopedic surgeon decided against pinning her hip. The patient, he said,had other medical problems and was too frail. He prescribed bed rest asthe best means of allowing the hip to heal. But not long after he beganthat treatment, the head of the right femur displaced, shortening the patient'sleg. She never regained the ability to walk.

Prior to her injury, the patient lived alone and maintained an independentlifestyle. She now lives in a nursing home, and is completely dependenton others. In a malpractice suit, she maintained that the surgeon deviatedfrom the standard of care in opting not to pin her hip. She also contendedthat he failed to obtain her informed consent to bed rest as an alternativeto surgery.

At trial, the court accepted the surgeon's argument that informed consentis irrelevant for noninvasive treatment. The issue of disclosure of alternativeprocedures was thus considered moot. The jury found in the doctor's favor.

A court of appeals, however, ruled that informed consent applies whetherthe treatment is invasive or not. The case was thus remanded back to trial.The New Jersey Supreme Court upheld the appellate court's findings.

Medical Practice: The debate over vaccine safety is heating up

The Association of American Physicians and Surgeons has called for amoratorium on hepatitis B vaccines for schoolchildren. Children youngerthan 14 who receive the vaccine, which contains a mercury-based preservative(thimerosal), are three times more likely to die or suffer adverse reactionsthan they are to catch the disease, says internist Jane M. Orient, AAPSexecutive director.

But the American Academy of Pediatrics and the US Public Health Servicecounter that there is no evidence of any harm caused to children who followedthe recommended immunization schedule. While acknowledging that an FDA studyfound that thimerosal exposure from the combination of all routine immunizationsin the first six months of life could exceed some government-recommendedlimits, they say the risk of not vaccinating children is far greater thanthose posed by exposure.

Still, the AAP and PHS have asked manufacturers for a "clear commitment"to reduce or eliminate the mercury content of vaccines as soon as possible.Until mercury-free alternatives are available, however, the AAP continuesto recommend that all children be immunized against the diseases listedin the 1999 Recommended Childhood Immunization Schedule.

Fraud and Abuse: Uncle Sam hammers a cost-cutting tactic

While acknowledging that hospitals need physicians' help in eliminatingunnecessary costs, HHS Inspector General June Gibbs Brown warned that payingdoctors to do so violates federal law. In a special advisory bulletin, Browntook issue with "gainsharing," a practice in which hospitals andphysicians divvy savings from reduced services to Medicare and Medicaidpatients.

Gainsharing could be made acceptable, Brown said, but only if Congresschanges existing federal regulations. Without adequate safeguards, the practicecould adversely affect patient care, and could be manipulated to rewardphysicians for patient referrals, she noted.

The IG's advisory bulletin also cautioned hospitals and physicians thatsome joint ventures may run afoul of the prohibition against hospitals payingdoctors to limit or reduce care. In particular, Brown cited freestandingspecialty hospitals (heart, orthopedic, or maternity) where services arecarved out of an existing hospital and recapitalized by physician investorsas a separate entity.

Editorially Speaking

From an Augusta (GA) Chronicle editorial, July 12, 1999, commendingthe Georgia Supreme Court for "striking down" the premise of "'wrongful' birth for the second time this decade."

" Look at what we've come to in this country: suing a doctor becausea baby lives. . . . There's nothing in nature--and there should benothing in the law--to guarantee every mom she'll have a healthy, normalbaby. Pregnancy is a risk . . . just one of life's chances. So if a babyis less than mentally or physically perfect, should a doctor have to paydamages for delivering it? Surely not."

Medicare: Once again, major HMOs are bailing out

Although HMOs doing business with Medicare will be paid about 5 percentmore next year, many are planning to bolt, according to a poll of AmericanAssociation of Health Plans members. This will force hundreds of thousandsof Medicare beneficiaries to find new health coverage. And millions morewill be affected by benefit cuts and higher premiums, the AAHP says.

Among the HMOs that will scale back Medicare participation: UnitedHealthcare,which will withdraw from 49 counties in which it offers Medicare coverage,Humana (31 counties), Foundation Health Systems (32 counties), PacifiCareHealth Systems (12 counties), and Aetna US Healthcare (5 counties). Theinsurers blame the Balanced Budget Act of 1997's effect on reimbursement,and fears about future coverage mandates.

Medicare managed care is in trouble, according to Wall Street analysts.They, too, point to inadequate payment rates as well as proposed risk-adjustmentpolicies. If the effort to add prescription drug coverage to the benefitpackage succeeds, the outlook is even grimmer, the analysts say. The prescriptionbenefit is Medicare managed care's key competitive advantage.

Senior Residents: Ardor cools between recruiters and recruits

Although recruiters are no longer beating down the doors of young primarycare physicians, demand for graduating generalists remains high, accordingto a survey by Merritt, Hawkins & Associates, a national physician searchfirm.

As in years past, US-trained residents have better odds of getting ajob than their foreign-trained counterparts. Fifty-three percent of residentstrained here received more than 25 solicitations during residency, comparedwith 31 percent of international medical graduates.

Still, a growing number of young doctors now question their career choice.The number who said they would select another profession if they had itto do over jumped from 5 percent in 1997 to 11 percent this year. And forthe first time since the biannual survey was launched in 1991, the fearthat "medicine might not be the right career" appeared on thelist of seniors' major concerns.

1.An arrangement whereby physicians share staff and office, but not finances.

2. Includes academic, locum tenens, urgent care, and no preference.

Source: Merritt, Hawkins & Associates 1999 Survey of Final-Year MedicalResidents

By Joan R. Rose, Senior Editor

Joan Rose. Practice Beat.

Medical Economics

1999;16:26.