Coding, coverage, and compensation for pathology and laboratory medicine services

Compensation for pathologist and clinical laboratory services generally depends upon standardized procedural coding systems, the coverage determinations of individual insurance companies, fee schedules that assign reimbursement rates for those services, and contractual compensation arrangements. Procedural coding relies primarily on the American Medical Association's Current Procedural Terminology (CPT) nomenclature. Disease conditions, signs, and symptoms are coded using the International Classification of Diseases, Ninth Revision, Clinical Modification. The single largest health insurance "company" in the United States is the Center for Medicare and Medicaid Services (CMS), and most private insurance companies look to CMS as a model for health services compensation. CMS uses a Physician Fee Schedule and a separate Clinical Laboratory Fee Schedule, whose designs and annual updates differ.     

Carrier discretionary practices and physician payment under Medicare Part B: a preliminary report.

Although Medicare is a national program, administration of Part B payments to physicians is in the hands of insurance organizations in ten Medicare regions. The carriers follow varying practices in using actual charges within localities as the basis for determining reasonable charges for physicians' services. While some of these practices have already been shown to influence fee levels, reasonable charge determination involves many more whose influence has not been systematically studied. This paper reviews preliminary findings from a study which examines carrier differences in discretionary practices as to specialties, localities and other claims data that may be merged or compared with Medicare data in determining customary and prevailing prices used to set limits on Medicare payments, and other practices reported in an official questionnaire to carriers. The effect on fee levels and other measures of program performance is being studied after taking into account social, economic and health resource variables extracted from the Area Resource File, that are expected to influence local medical prices through the demand for and supply of physicians' services. Dependent variables representing fees are the 50th percentile of the distribution of weighted customary charges of individual physicians in an area and Supplementary Medical Insurance expenditure per enrollee. The preliminary findings in this paper concern discretionary practices, socioeconomic variables and fee distributions.     

Risk management and medical malpractice.

Medical malpractice claims are common and may be emotionally difficult for physicians. Most malpractice suits claim negligence. The most frequent types of claims include failure or delay in diagnosis, negligent treatment with drugs, failure to obtain consultation, failure to obtain informed consent, and negligent management of procedures. The most important risk-management strategy is the provision of good medical care. If a claim is filed, physicians should cooperate fully with the malpractice insurance carrier and refrain from discussing the case with colleagues.     

Differences in attitudes toward terminal patients among selected medical specialities of physicians.

Medical specialty of physicians was related to attitudes toward dying patients to determine if differences occur as suggested by the literature. Data from a questionnaire completed by 1,012 physicians from the classes of 1972--1975 in five selected medical schools were analyzed using the chi-square distribution to test the relationship between the response to each of the 11 Likert-type statements and the medical specialty of the physicians. Mean responses by medical specialty to the statements were ranked and correlated to Rea's ranking with respect to the probability of dealing with terminal patients by specialty using a Spearman Rank Correlation Coefficient. Support was found for Rea's conclusion that physicians such as oncologists with a high probability of relating to dying patients tended to be more open with the patient whereas a specialty like obstetrics-gynecology with a low probability tended to operate in more of a closed awareness context.     

护理人员对医疗纠纷和相关法律、法规认知状况的调查与分析

目的调查分析当前发生医疗纠纷的现状、护患双方的态度、主要原因、护理人员对有关医疗法律、法规的知晓程度,提出相应对策。方法自行设计调查表,随机对江苏省5所综合性三级甲等医院发放调查表409份,由护理人员自愿填写,回收且资料完整进入统计的378份,占总发放数92%。结果调查表明患者与护士发生医疗纠纷的现状分别为:护士被骂占47.88%、被打占5.02%,发生纠纷占13.2%。护理人员对发生医疗纠纷的认识分别为:主要责任医患双方。主动沟通可以有效的减少矛盾。处理医疗纠纷最佳时间在萌芽状态。护患纠纷发生的主要原因前3位分别为:患者对医疗费用不满,缺乏与患者沟通交流,违反操作常规。护理人员对《医疗事故处理条例》相关知识知晓程度分别为:医生下达口头医嘱不执行占2.65%,医务人员是不是医疗事故的主体,回答是的占48%。护理人员对医疗相关法律、法规知晓程度:护士未取得执业证书回答不可以执业的仅占11.64%,学习过《中华人民共和国护士管理法》、《母婴保护法》者分别为:60.23%、44.71%。结论医疗纠纷其构成复杂,形式多样,加强护患沟通,制定突发事件预案,加强风险管理和有关法律、法规学习有利于减少纠纷发生。     

Further development of peer-review-procedures in medical rehabilitation

In 2002, the peer review for the somatic indications of medical rehabilitation was further developed. This process was aimed at adjusting the peer review checklist to the "Guide for the Uniform Medical Report of the Statutory German Pension Insurance Scheme" ("Leitfaden zum einheitlichen Entlassungsbericht der Rentenversicherung"), at harmonising the peer review with the version used in the quality assurance programme of the German health insurance and at reducing requirements by focusing on criteria relevant in the individual case. This paper reports on the consensus process carried out and outlines the modifications of the peer review procedure.     

Management of emergencies in the medical office

As a result of requests by members of the medical staff, a course entitled "Management of Emergencies in the Medical Office" was developed by an emergency physician and was taught at the 1984 Annual Scientific Meeting of the Michigan State Medical Society. Forty-two of the 100 physician participants responded to a questionnaire given during the course. More than 50% stated that each of the above-listed emergencies had occurred in their offices more than once. Eleven percent had adequate equipment to manage common office emergencies. Seventy-nine percent were BCLS-certified, 35% were ACLS-certified, 19% had defibrillators, 35% had intravenous (IV) catheters, and 40% had laryngoscopes. The questionnaire shows that a large percentage of office physicians are poorly prepared to deal with common office emergencies. This educational deficiency presents a good opportunity for emergency physicians to interact with their colleagues. This type of positive educational experience may lead to better rapport between the staff and emergency physicians.     

上海市老年医疗护理机构脑卒中康复现状调查

目的了解目前上海市老年医疗护理机构脑卒中康复资源现状,以期为脑卒中单病种护理质量控制提供指导。方法 2016年3月,整群抽取上海市老年护理管理质量控制中心督查范畴的老年护理院、社区卫生服务中心以及设置老年护理床位的区县综合医院等68所医疗机构为研究对象。采用问卷调查法调查其2015年收治脑卒中及卒中后遗症患者人数、平均住院天数、平均床日费用、医疗保险报销比例、各年龄段老年患者比例、康复开展状况等。结果上海市老年医疗护理机构康复护理设施配置完善程度不一,72.1%的机构单独设置康复科;康复护理人力以初级职称人员为主,占70.37%,各机构人员配置差异较大。脑卒中/卒中后遗症患者呈高龄化趋势,80岁以上患者占55.39%,且女性多于男性;医疗保险可报销比例为18%~100%;各机构平均床日费用及平均住院天数差别较大。结论目前上海市老年医疗护理机构康复资源较为薄弱,分布不均;需强化康复医护人员队伍建设,探索脑卒中单病种医疗付费和医疗保险模式;发展脑卒中家庭康复,提供延续性医疗护理服务。     

Malpractice litigation for uninformed consent. Implications for physical therapists

Although physicians generally are expected to secure their patients' informed consent to medical treatment, an emerging body of legal opinion holds that in certain situations nurses and allied health care professionals may be found similarly responsible. Failure of a health care provider to protect a patient's right of informed consent might result in a lawsuit alleging that serious harm was sustained needlessly because the patient plaintiff was not informed of certain significant risks of or consequences that resulted from treatment. As a professional group that puts patients at risk of harm during treatment, physical therapists need to know about their legal duty to facilitate a patient's awareness of and consent to treatment. This article discusses the nature of that duty and how a patient plaintiff might try to prove negligence against a physical therapist who allegedly fails to secure a valid statement of informed consent. The article also provides recommendations so that physical therapists might protect themselves from malpractice suits alleging "uninformed" consent.     

Informed consent in the intensive care unit: ensuring understanding in a complex environment

PURPOSE OF REVIEW: Informed consent in the intensive care unit continues to receive marked attention. As greater numbers of patients enter into the intensive care unit with devastating illness, patients and families are faced with more complex medical problems and decisions regarding therapy. Furthermore, research investigations of critical illness add a level of complexity to informed consent and decision making that mandates a careful approach. RECENT FINDINGS: Publications in the past year evidence the potential obstacles for appropriate informed consent. Physicians demonstrate variability in interpretation for the need for informed consent and frequently lack formal training in communicating informed consent. Critical care researchers must communicate the goals and benefits of trial participation carefully, avoiding the demonstrably common pitfall of therapeutic misconception. Excellent consensus statements now exist to guide the researcher in pursuing critical care research, creating informed consent documentation, and recognizing the appropriate setting for waiver of consent. As expected, extended discussion is the most effective tool for improving the quality of informed consent. SUMMARY: Quality of informed consent for the critically ill improves as attention is paid to standardizing indications and formalizing training for physicians. In research, conflicts of interest should be recognized and used to guide the investigator's dialogue on research benefits and risks. Patient safety must be maintained as the primary priority; however, waiver of consent may be considered in situations in which the benefit to medical knowledge far exceeds patient risk.     

Comparison of work and time estimates by chiropractic physicians with those of medical and osteopathic providers.

BACKGROUND: Resource-based relative value scales (RBRVS) have become a standard method for identifying costs and determining reimbursement for physician services. Development of RBRVS systems and methods are reviewed, and the RBRVS concept of physician "work" is defined. OBJECTIVE: Results of work and time inputs from chiropractic physicians are compared with those reported by osteopathic and medical specialties. Last, implications for reimbursement of chiropractic fee services are discussed. METHODS: Total work, intraservice work, and time inputs for clinical vignettes reported by chiropractic, osteopathic, and medical physicians are compared. Data for chiropractic work and time reports were drawn from a national random sample of chiropractors conducted as part of a 1997 workers' compensation chiropractic fee schedule development project. Medical and osteopathic inputs were drawn from RBRVS research conducted at Harvard University under a federal contract reported in 1990. Both data sets used the same or similar clinical vignettes and similar methods. Comparisons of work and time inputs are made for clinical vignettes to assess whether work reported by chiropractors is of similar magnitude and variability as work reported by other specialties. RESULTS: Chiropractic inputs for vignettes related to evaluation and management services are similar to those reported by medical specialists and osteopathic physicians. The range of variation between chiropractic work input and other specialties is of similar magnitude to that within other specialties. Chiropractors report greater work input for radiologic interpretation and lower work input for manipulation services. CONCLUSIONS: Chiropractors seem to perform similar total "work" for evaluation and management services as other specialties. No basis exists for excluding chiropractors from using evaluation and management codes for reimbursement purposes on grounds of dissimilar physician time or work estimates. Greater work input by chiropractors in radiology interpretation may be related to a greater importance placed on findings in care planning. Consistently higher reports for osteopathic work input on manipulation are likely attributable to differences in reference vignettes used in the respective populations. Research with a common reference vignette used for manipulation providers is recommended, as is development of a single generic approach to coding for manipulation services.     

The role of the consent document in informed consent for pediatric leukemia trials

PURPOSE: To examine both the use of the consent document during the informed consent process for pediatric leukemia clinical trials, as well as relationships between the use of the document and parental understanding of essential elements of informed consent. METHODS: Participants included 140 parents of children diagnosed with pediatric leukemia. Informed consent conferences in which randomized clinical trials were discussed were observed, audiotaped, and coded for specific behaviors. Parents were also interviewed within 48 h of their participation in informed consent conferences. RESULTS: Observations revealed that 74% of cases included explanation of consent documents during consent conferences. Parents who reported that they read the consent document were more likely to understand differences between the clinical trial and off study therapy and were more likely to understand the right to withdraw. Reading of the consent document was not associated with understanding of voluntariness. In comparison to racial/ethnic majority parents, racial/ethnic minority parents were less likely to report that they read the consent document, understand voluntariness or the right to withdraw, and were less likely to be able to distinguish between the clinical trial and off study therapy. Low SES was associated with a lower probability of reading the consent document and being able to distinguish between clinical trials and off study therapy. CONCLUSIONS: Attention to the importance of reading the consent document and improving communication during consent conferences is likely to enhance understanding of essential elements of informed consent.     

《侵权责任法》系列讲座之二:法律适用相关问题

《侵权责任法》试图建立一元化结构的医疗损害责任制度,引致《医疗事故处理条例》(《条例》)的存废之争。作者认为,围绕医患纠纷的民事赔偿法律规制,今后绝不会归于"一元化",而是继续保持甚至愈加"多元化"的态势。《侵权责任法》与《条例》肯定将并行不悖、各有侧重与分工。除《条例》将继续发挥规制作用外,对于《侵权责任法》生效之前诊疗行为结束并已出现损害后果的案例,事发当时有效的其他含有侵权责任规定的法律可能被优先适用,国际公约《经济、社会和文化权利国际公约》第12条及其拓展性文件规定了庞杂的"健康权"相关内容,亦不排除被优先于《侵权责任法》适用的可能性。     

Physicians view national health insurance: a national study.

Nationally representative samples of senior physicians, interns and residents, and medical students were interviewed during the spring of 1973. The main focus of the present analysis is senior physicians' responses to national health insurance issues. The level of support among physicians is underestimated by physicians themselves. Despite the fact that 56 per cent of the doctors were in favor of "some form of national health insurance," almost three-fourths of the respondents believed that most doctors they knew personally were opposed. More than four-fifths of the physicians believed that NHI was inevitable, and those who saw NHI as inevitable were more likely to favor it. Doctor's views about NHI were closely related to their general political views. In general, attitudes of AMA members and grass-roots state and local medical society leaders were not greatly divergent. In terms of responses to specific components differentiating NHI alternatives, physicians preferred conservative options on how a program was to be financed and administered as well as whether the development of prepaid groups should be encouraged. Support for the liberal alternative was strongest on the question of peer reviews, with 75 per cet in favor of such reviews under a NHI program. Differentiation in the profession is considerable. Main activity, work setting, specialty, percentage of income in salary, geographical location, and career stage all contribute to differing reactions to NHI among physicians.     

Physicians' assessments of their ability to provide high-quality care in a changing health care system

BACKGROUND: With the growth of managed care, there are increasing concerns but inconclusive evidence regarding deterioration in the quality of medical care. OBJECTIVES: To assess physicians' perceptions of their ability to provide high-quality care and explore what factors, including managed care, affect these perceptions. RESEARCH DESIGN: Bivariate and multivariate analyses of the Community Tracking Study Physician Survey, a cross-sectional, nationally representative telephone survey of 12,385 patient-care physicians conducted in 1996/1997. The response rate was 65%. PARTICIPANTS: Physicians who provide direct patient care for > or =20 h/wk, excluding federal employees and those in selected specialties. MEASURES: Level of agreement with 4 statements: 1 regarding overall ability to provide high-quality care and 3 regarding aspects of care delivery associated with quality. RESULTS: Between 21% and 31% of physicians disagreed with the quality statements. Specialists were generally 50% more likely than primary care physicians to express concerns about their ability to provide quality care. Generally, the number of managed care contracts, but not the percent of practice revenue from managed care, was negatively associated with perceived quality. Market-level managed care penetration independently affected physicians' perceptions. Practice setting affected perceptions of quality, with physicians in group settings less likely to express concerns than physicians in solo and 2-physician practices. Specific financial incentives and care management tools had limited positive or negative associations with perceived quality. CONCLUSIONS: Managed care involvement is only modestly associated with reduced perceptions of quality among physicians, with some specific tools enhancing perceived quality. Physicians may be able to moderate some negative effects of managed care by altering their practice arrangements.     

Physicians attitudes toward DNR of terminally ill cancer patients in Taiwan

The purpose of this study was to survey physicians attitudes toward DNR of terminally ill cancer patients in Taiwan. A total of 7626 structured questionnaires were sent by mail to physicians who were members of the Taiwan Society of Internal Medicine and the Surgical Association of Taiwan, and 1328 valid responses were received. The response rate was 17.6%. The instrument, a structured questionnaire, was composed of one scenario and six questions. A majority (77.6%) of the physicians under investigation would tell a terminally ill cancer patient or his family about the possibility of DNR and ask them to consider signing a consent form. Over one half of the physicians (58.4%) did not know whether the Medical Law in Taiwan permits natural death, and 96.1% of the subjects felt they would need legal protection for agreeing patient s autonomy to decide DNR. Unfortunately, 41.2% of the respondent admitted that they did not have a formal Informed Consent Form that could be used for DNR. Even of those who had such a form, only 27.4% had clear guidelines given by their institutions. Among 623 physicians whose institutions had an formal Informed Consent Form for DNR, 63.7% agreed that it was reasonably used. Surprisingly, 67.9% of the physicians had used Slow Codes. The findings of this study served as a solid base. The investigator and other colleagues used it to convince legislators to pass a Natural Death Act in Taiwan. Since some legislators disliked the term death and the main promotes were people engaged in hospice palliative care, the new law entitled Hospice Palliative Act was passed on May 23, 2000. The DNR order finally gained its legal base for medical practice. The limitation of this study was the low response rate. However, since the subjects, physicians, had a busy work load, this was still an acceptable response rate.     

Using principles of health literacy to enhance the informed consent process

THE LANGUAGE COMMONLY used in procedural/surgical consent forms often exceeds the average reading level of US patients, and many do not read the document before signing it.INCORPORATING READER-FRIENDLY language and formatting makes it more likely that patients will read the document, understand it, and therefore give informed consent. Adding “teach back” into the document provides a means of evaluating patient understanding.USING READER-FRIENDLY procedural/surgical consent documents merges the objectives of both health literacy and informed consent. AORN J 88 (July 2008) 23-29. © AORN, Inc, 2008.     

What is anaesthesiology worth in the German DRGs?--First experience with German DRGs

This overview reports on first experience with German DRGs version 1.0 from 2003, with special regard to relevant procedures and diagnoses of anaesthesiology. Basically, the G-DRGs are a translation of the AR-DRGs 4.1. Only the 2004 version represents a first "real" German DRG system. Particularly anaesthesiological measures for procedures which are normally performed without narcosis can lead to essentially relevant remuneration. In intensive care medicine, the hours of artificial ventilation must be recorded exactly. In the 2004 version of the G-DRGs, intensive medical performances are mainly differentiated regarding the time of ventilation, which leads to better payment than under version 1.0. In intensive care medicine, additional remuneration is only intended for dialyses and other organ-supporting procedures. Pain therapy is insufficiently documented in the G-DRGs. Although new codes of pain treatment are included in the G-DRGs, they do not lead to relevant remuneration. Diagnoses and procedures coded by the anaesthetist should be registered in the clinic information system without delay. Only non-anaesthesia-associated diagnoses, i.e. additional diagnoses resulting from the preanaesthetic check-up of the patient in the preanaesthetic department, should be checked by non-anaesthesiological physicians. The correct documentation and transfer of ASA classifications is necessary for additional charges in external quality management and to avoid financial sanctions. In our experience, regarding operated patients, anaesthetists can contribute a lot to enquiries by health insurance companies, e.g. whether the payment code for an in- or an out-patient should be used. Departments of anaesthesia should appoint an anaesthetist as DRG representative to supervise anaesthesiological coding and DRG-relevant procedures.     

Patient preferences for medical decision making: who really wants to participate?

OBJECTIVES: To identify the determinants of patient preferences for participation in medical decision making. METHODS: Data were analyzed for 2,197 patients from the Medical Outcomes Study, a 4-year observational study of patients with chronic disease (hypertension, diabetes, myocardial infarction, congestive heart failure, and depression). Multivariate logistic regression models estimated the effects of patients' sociodemographic, clinical, psychosocial, and lifestyle characteristics on their decision-making preferences. RESULTS: A majority of the patients (69%) preferred to leave their medical decisions to their physicians. The odds for preferring an active role significantly decreased with age and increased with education. Women were more likely to be active than men (odds ratio [OR] = 1.44, P < 0.001). Compared with patients who only suffered with unsevere hypertension, those with severe diabetes (OR = 0.62, P = 0.04) and unsevere heart disease (OR = 0.45, P = 0.02) were less likely to prefer an active role. Patients with clinical depression were more likely to be active (OR = 1.64, P = 0.01). Patients pursuing active coping strategies had higher odds for an active role than "passive" copers, while those who placed higher value on their health were less likely to be active than those with low health value (OR = 0.59, P < 0.001). CONCLUSIONS: Although a majority of patients prefer to delegate decision making to physicians, preferences vary significantly by patient characteristics. Approaches to enhancing patient involvement will need to be flexible and accommodating to individual preferences in order to maximize the benefits of patient participation on health outcomes.