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Please answer ALL questions below. Limit your answers to ONE PAGE per question typed double-spaced. Emphasis should be on building economic model(s) that captures the central point of each question with short paragraphs explaining the assumptions you have made to construct the model(s).

1.      In the article below, the CMS is planning to pay for care coordination. Using economic model(s) discuss intended policy to pay for care-coordination. Make sure you identify the product/services before you start answering the question. (Care coordination is not a product)

Published: Aug 18, 2014

By Joyce Frieden, News Editor, MedPage Today

WASHINGTON -- The Centers for Medicare and Medicaid Services (CMS) has announced that Medicare will cover care coordination services for chronically ill patients starting next year, but at least one physician group says the reimbursement being offered is not high enough.

As part of the final rule for the 2014 Medicare physician fee schedule which was issued in December 2013, CMS announced last year that it would begin covering these services in January 2015. However, not many details were provided.

In another rule published on July 3, 2014, more detail about the new fee emerged. The agency proposed a reimbursement of $42 for the service -- covered under codes 99487-99489 -- which applies to "chronic care management services furnished to patients with multiple chronic conditions that are expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline."

Medicare already pays for care coordination when patients transition from hospital care to outpatient care; the new code adds to that by covering coordination for ongoing chronic illness care.

"Overall we're very supportive of CMS moving in this direction," Shari Erickson, vice president of the American College of Physicians, told MedPage Today. "This is something we've been encouraging for quite some time."

However, added Erickson, who spoke while a media relations person was present, "a survey we conducted on a CPT code with same descriptor ... put [adequate reimbursement] at the $70 to $80 payment range, so we'll be providing some suggestions to CMS to have a few different approaches and some options to consider as they move the code forward."

The American Academy of Family Physicians (AAFP) is also supportive of the proposed new code, according to AAFP president Reid Blackwelder, MD.

"In general we support this as a step in the right direction," Blackwelder, a family physician in Kingsport, Tenn., told MedPage Today. "The reality is that this kind of coordination of care is something ... that we do and have done for very long time. Unfortunately, we haven't had a mechanism to be paid for it."

When it comes to setting the reimbursement rate for the code, there are several factors to consider, he said. "One of the challenges for patients is that with our current system ... they still have to pay for services they get, including this coordination -- they still have responsibility for a 20% copay," so setting the fee higher might be a problem for some patients.

Another issue with the new code is that in order to be eligible to be paid for it, a physician must have a certified electronic health record (EHR) system, Blackwelder noted.

"Family physicians, as a specialty, really have led the way in transforming to EHRs -- close to 70% of members have EHRs," he said. "However, 30% of our members don't, and other physician groups have fewer numbers of practices who have EHRs."

2.      In the article below, NPs (Nurse Practitioners) and PAs (physician assistance) have been performing in-office procedures that are traditionally reserved for specialists. The pressure from all sources requires more efficient use of resources in delivering medical care. Using economic model(s) discuss implications of allowing NPs and PAs to deliver a larger number of services on the market for medical care industry.

Practice Management

Cardiology: Turf Wars, Battle Lines

Published: Aug 26, 2014

By Kevin Campbell

Kevin Campbell, MD is a cardiologist at UNC Health Care in Chapel Hill, N.C., and weekly contributor for Fox News and Fox Business. Here, Campbell expands on his thoughts on the recent Friday Feedback that asked healthcare providers: How big a problem are turf wars in medical care and what are some solutions?

Last week, MedPage Today reporter Sarah Wickline Wallan tackled a very controversial issue in medical practice: turf wars.

In her piece, Wallan explored the ongoing battle between dermatologists and AHPs (Allied Health Professionals) over the performance of dermatologic procedures.

As independent NPs and PAs begin to bill for more and more procedures (thus potentially talking revenue away from board certified Dermatologists) specialists are beginning to argue that the AHPs are practicing beyond their scope of practice.

According to the Journal of the American Medical Association, nearly 5 million dermatological procedures were performed by NPs and PAs last year -- this has dermatologists seeking practice limits -- ostensibly to protect "bread and butter" revenue streams from biopsies, skin tag removals and other common office based interventions.

Valued Team Members

First of all, I want to say that AHPs are essential to providing care in the era of the Affordable Care Act. NPs and PAs are able to help meet the needs of underserved areas and do a remarkable job complementing the care of the physicians with which they work. With the rapidly expanded pool of newly insured, as well as the increase in administrative tasks (electronic documentation) assigned to physicians, AHPs must help fill in the gaps and ensure that all patients have access to care.

In my practice we are fortunate to have many well qualified AHPs that assist us in the care of our patients both in the hospital as well as in the office.

We must remember, however, that physicians and AHPs have very different training.

Each professional possesses a unique set of skills and each skill set can complement the others.

Many of us in specialty areas spend nearly a decade in post MD training programs and learn how to care for patients through rigorous round-the-clock shifts during our residency and fellowship years.

In addition, we spend countless hours performing specialized procedures over this time and are closely supervised by senior staff. Most AHPs, in contrast, do not spend time in lengthy residencies and often have limited exposure to specialized procedures. Turf battles have existed for decades and are certainly not limited to Dermatology -- nor or they limited to MDs vs AHPs.

Lessons from Earlier Skirmishes

In cardiology in the late 1990s, for instance, we struggled with turf battles with radiology over the performance of peripheral vascular interventions. In many areas, these battles resulted in limited availability of specialized staff to patients and a lack of integrated care. Ultimately, the patients were the ones who suffered.

Fortunately, in the UNC Healthcare system where I work (as well as others across the country) we have taken a very different approach. After observing inefficiencies and redundancy in the system, several years ago our leadership (under the direction of Cam Patterson, MD) decided to make a change. The UNC Heart and Vascular Center was created -- Vascular surgeons, Cardiologists, Interventional Radiologists, and Cardiothoracic surgeons -- all working under one cooperative umbrella.

Patients are now discussed and treated with a multidisciplinary approach -- electrophysiologists and cardiothoracic surgeons perform hybrid atrial fibrillation ablation procedures, vascular surgeons and interventional Cardiologists discuss the best way to approach a patient with carotid disease -- all working together to produce the BEST outcome for each individual patient.

We have seen patient satisfaction scores improve and we have noted that access to multiple specialty consultations has become much easier to achieve in a timely fashion. Most importantly, communication among different specialties has significantly improved.

Unfortunately, with the advent of the ACA and decreasing reimbursement I suspect that turf battles will continue.

Financial pressures have become overwhelming for many practices and the days of the private practice are limited -- more and more groups will continue to "integrate" with large hospital systems in the coming years. Specialists such as dermatologists and others will continue to (rightly so) protect procedures that provide a revenue stream in order to remain financially viable.

First and Last: Do No Harm

As physicians we must also protect our patients from harm. Physicians spend years of training learning to care for particular disease states and have a greater understanding of procedural related complications than other allied health professionals. with the advent of the ACA, PAs and NPs will play a much larger role in the delivery of care.

While I believe it is essential to increase the utilization of allied health professionals such as NPs and PAs in order to best serve the needs of a growing patient population, I do not believe that they should be allowed to perform complex procedures such as heart catheterizations and pacemaker implantations (I have seen this practice increasing at several major academic institutions).

These procedures should be performed by Fellowship trained physicians who have spent numerous years in training and have learned (under attending supervision) to handle procedural related complications and respond to unexpected developments during a case.

However, I believe that our time will be better spent by working together to improve efficiency of care, quality of care and integration of care. NPs and PAs are going to be a critical component to health care delivery as we continue to adapt to the new (and ever changing) ACA mandates.

We must put patients FIRST -- turf battles and squabbles amongst healthcare providers will only limit our ability to provide outstanding, efficient care. Let's put the most qualified person in the procedure room -- and make sure that ultimately patients get exactly what they need.

3.      In the article below, similar to End-of-Life debate, there is a discussion around futile or pointless medical care and how resources allocated in one area can and does affect welfare of others who could benefit from the use and application of the same resources… In the context of material we have discussed so far in the course, discuss.

Futile ICU Care for Some Delays Care for Others

Published: Aug 22, 2014 | Updated: Aug 25, 2014

By Charles Bankhead, Staff Writer, MedPage Today

Reviewed by Zalman S. Agus, MD; Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

Providing futile care to ICU patients delayed care for other patients awaiting transfer into the ICU, according to a 3-month study of ICU practices at two hospitals.

Overall, 81 of 463 patients admitted from the emergency department (ED) to the ICU were transferred when the ICU was at capacity and one or more patients were receiving what clinicians considered futile care. In 33 of the 81 cases, patients had to remain in the ED for 4 hours or longer while awaiting transfer.

Among patients transferred from other hospitals, 16 waited a total of 42 days when the ICU was full, including nine patients and 16 days when at least one patient was receiving futile care. An additional 37 transfer requests were canceled, including requests for 15 patients who had waited an average of 2 days each when the ICU was full and a patient was receiving futile care, as reported online in Critical Care Medicine.

"These are the kind of data that should generate a public discussion," senior author Neil Wenger, MD, of the University of California Los Angeles and RAND Health in Santa Monica, Calif., told MedPage Today. "The public discussion about advance care planning was largely stifled in the context of healthcare reform by calls about death panels.

"Yet, these are the kinds of data that need to be considered in open, thoughtful public discussion, when one thinks about providing treatments toward the end of life that don't benefit the patients receiving them, at least from the perspective of the physician, but that may very well benefit the patients who are not able to receive treatment."

The study shed light on an issue common to ICUs everywhere but that often is discussed only with reluctance, said Michael Anderson, MD, of University Hospitals Case Medical Center in Cleveland.

"It's a very difficult and very delicate topic to deal with," Anderson told MedPage Today. "I think the authors do talk about the importance of discussions with families, when hope really has run out, and to make some very difficult decisions."

Ongoing Study

Last year Wenger and colleagues reported that intensive care specialists said they definitely or probably were providing futile care to 20% of ICU patients. Most of the ICU clinicians considered the care futile "because the burdens grossly outweighed the benefits." Investigators estimated that the futile care cost $2.6 million.

Using data from the same study, the authors continued the investigation with an analysis aimed at determining how frequently the care for other patients was delayed by futile care. The study involved 36 critical care specialists at a referral center and affiliated community hospital. Four specialty ICUs at the referral hospital were included in the study: medical (MICU), neurocritical care (NCU), cardiothoracic (CT-ICU), and cardiac care (CCU).

The primary outcomes were boarding time in the ED and waiting time on the transfer list.

The clinicians performed 6,916 assessments of 1,136 patients during a 92-day study period. In the ICU doctors' judgment, they provided futile care to 123 (11%) patients and "probably" provided futile care to another 98 (8.6%).

The 123 patients received a cumulative total of 464 days of futile treatment, which accounted for 6.7% of all assessments. The authors found that 68% of patients who received futile care died in hospital, and 85% died within 6 months. Survivors lived with severely compromised health.

In contrast, patients who did not receive futile treatment had a hospital mortality of 4.6% and 6-month mortality of 7.3%.

The five ICUs provided a total of 460 days of care, more than half (255, 55%) of which included at least one patient receiving futile care. Across the five units, the proportion of days with futile care ranged from 88 of 92 days in the MICU to 15 of 92 days in the CCU.

Supply and Demand

ICU census had a substantial impact on the likelihood that one or more patients were receiving futile care. The ICUs were at capacity on 191 of 460 (42%) days, ranging from 18 (20%) days at the community hospital to 55 (60%) days at the CT-ICU. The five ICUs provided futile treatment on 72 of 191 (38%) days at full capacity versus 183 of 269 (68%) days when they were not full (P<0.001).

Admission to the ICU from the ED also was affected by bed status, as delays of 4 hours or more occurred on 61% of days when ICUs were at capacity versus 35% when not at capacity (P=0.05). Among patients who boarded for at least 4 hours in the ED, the median wait time was 339 minutes.

The ICUs received 163 transfer requests from outside hospitals during the study period. In 104 cases, patients were transferred within 1 day of the request. The wait lasted more than a day for 22 patients, including nine patients who waited a total of 16 days while an ICU was at capacity and providing futile care.

Transfer requests were canceled in the remaining 37 cases, including 15 patients who waited a day or longer when the ICU was full and a patient was receiving futile care. Of those 15 patients, five were transferred to other hospitals, three patients improved and did not require ICU care, four patients were lost to follow-up, one was discharged to a skilled nursing facility, and two patients died while waiting for transfer.

Although the study documented the futile care, the data offered no insights into why doctors provided the care.

"We know why the physicians said that the treatment was futile, but we don't know why they provided it anyway," said Wenger. "The implication is that they're being asked to provide it, because otherwise they would have stopped."

Need for Discussion

Many physicians recognize that some of the care provided might be futile, but they might not see it from a broader perspective, said Michele Moss, MD, a pediatrics intensivist at the University of Arkansas for Medical Sciences in Little Rock.

"I don't know that physicians think about how futile care affects other patients," Moss, a spokesperson for the Society of Critical Care Medicine, told MedPage Today. "That's the strength of this study. It points out that there are downstream effects on other patients in certain circumstances."

Futile care ties directly to ongoing discussion about end-of-life care and advance care directives, which are never easy discussions but can be facilitated by involvement of patients' primary care physicians.

"I hope this study will encourage the conversation," said Moss. "I think we would all like to avoid it if possible, but I think this study points out the importance of having those conversations as part of our daily work.

"The other piece of the discussion is the involvement of primary care physicians. As hospital workers we never have met these patients, and now we are having difficult conversations with them or their families about futile care or limitation of care. Whenever patients have primary care physicians, they can be very helpful in these circumstances involving difficult conversations because they have a relationship with the patients."

Indirectly, the study also raises the issue of how to allocate scarce healthcare resources, said medical ethicist Howard Brody, MD, PhD, of the University of Texas Medical Branch at Galveston.

"The main lesson [of the study] is the impact of care on others," Brody told MedPage Today. "Is there some way in which the care of this patient is always going to affect the care of another patient? If this patient gets this care in this time and this fashion and this place, that means something is not available to some other person."

Scarcity is an issue that will probably become more common in the future, he added, alluding to the ongoing shortages of certain commonly used generic cancer drugs that are no longer profitable for manufacturers.

"I think we are going to see more and more instances of scarcity affecting larger numbers of patients," said Brody. "In many cases, the scarcity will be hidden and not obvious, and we will have to be very careful about watching to see where they pop up."

4.       In the article below, it is proposed to raise the Medicare age to 67. Using economic theory discuss the implications of this legislation on the medical care services.

Bill Would Raise Medicare Age to 67

Sens. Joseph Lieberman (I-Conn.) and Tom Coburn, MD (R-Okla.) released a Medicare proposal Tuesday that would stave off reimbursement cuts for physicians in the program for three years, but would raise Medicare eligibility to 67 and increase out-of-pocket expenditures.

Lieberman and Coburn said their bill will save Medicare $600 billion over 10 years, mainly shifting costs to beneficiaries and delaying the age at which the program pays out benefits.

For physicians, the bill offers a carrot in the form of a three-year "fix" for the sustainable growth rate (SGR) formula that determines physician reimbursement. That formula, which ties physician payment rates to changes in the gross domestic product, currently calls for a 30% cut in rates beginning Jan. 1, 2012.

Under the Lieberman/Coburn proposal, the fix would allow time for a new reimbursement system to be developed. The CBO estimates that extending the SGR for three years would cost $37.7 billion, the senators noted.

5.       In the article below, CDC has expressed concern with over prescription of antibiotics. Using economic model(s) discuss the implication of overused antibiotics on medical care services.

Primary Care 01.18.2016 0 Comments

CDC: Half of Antibiotic Prescriptions are Unnecessary

ACP, CDC remind doctors to be cautious about antibiotic prescribing

by Kristina Fiore Staff Writer, MedPage Today

Two doctor groups are reminding physicians to use antibiotics sparingly this cold and flu season.

The American College of Physicians and the CDC urged doctors not to dole out antibiotics for colds, sore throats, bronchitis, and sinus infections that aren't complicated, according to guidance published in the Annals of Internal Medicine.

"Reducing overuse of antibiotics for acute respiratory tract infections in adults is a clinical priority and a high-value-care way to improve quality of care, lower healthcare costs, and slow or prevent the continued rise in antibiotic resistance," Wayne Riley, MD, MPH, president of ACP, said in a statement.

Antibiotics are prescribed at more than 100 million adult ambulatory care visits every year, and 41% of these prescriptions are for respiratory conditions, the guidance states.

Antibiotic overuse contributes to the spread of antibiotic-resistant infections; in the U.S., there are 2 million antibiotic-resistant illnesses and 23,000 related deaths each year -- costing the healthcare system some $30 billion.

Data from the CDC suggest that about 50% of antibiotic prescriptions are unnecessary or inappropriate, equating to more than $3 billion in excess healthcare costs, the guidance states.

And antibiotics aren't without side effects. Indeed, they are responsible for the largest number of medication-related adverse events, implicated in 1 of every 5 emergency department visits for adverse drug reactions, the researchers said.

To remind physicians about good antibiotic stewardship, ACP and CDC focused on four conditions that most likely will resolve on their own: the common cold, uncomplicated bronchitis, sore throats, and uncomplicated sinus infection.

For uncomplicated bronchitis, physicians shouldn't conduct any tests, and should refrain from prescribing antibiotics, unless pneumonia is suspected. Patients can have cough suppressants, expectorants, antihistamines, decongestants, and beta agonists instead.

A sore throat should get analgesic therapy such as aspirin, acetaminophen, NSAIDs, or throat lozenges -- although testing can be done in patients with symptoms of group A streptococcal pharyngitis. That's the only case in which antibiotics would be warranted, the authors said.

An uncomplicated sinus infection usually resolves without antibiotics, even in patients with a bacterial cause, the guidance states. Patients can have anaglesics for pain and antipyretics for fever.

Antibiotics should be reserved for patients with symptoms lasting more than 10 days, if they start to develop severe symptoms or signs of a high fever (above 39°C/ 102.2°F), or if they have nasal discharge or facial pain that lasts three consecutive days.

The authors disclosed no financial conflicts of interest.

• Primary Source

Annals of Internal Medicine

Source Reference: Harris AM, et al "Appropriate antibiotic use for acute respiratory tract infection in adults: Advice for high-value care from the ACP and CDC" Ann Intern Med 2016; DOI: 10.7326/M15-1840.