Joyce Frieden

Carotid Stent Guidelines Released

A coalition of groups has released a set of guidelines for determining when physicians are qualified to perform carotid artery stenting. “This is a very rigorous set of standards,” said Kenneth Rosenfield, M.D., director of cardiac and vascular invasive services at Massachusetts General Hospital in Boston. “This sets the bar very high.” The standards call for physicians to first be proficient in other types of stenting, and then to perform a minimum of 30 diagnostic angiograms and 25 carotid stenting procedures under supervision. They also call for physicians to be skilled in risk assessment, diagnosis, and alternative therapies for the patients involved, and to report and analyze their outcomes. The document notes that physicians of many different subspecialties will seek the training; one of the issues in developing the guidelines had been whether to restrict training only to certain specialists.

Neuroscience Partnership at NIH

The National Institutes of Health is breaking down barriers between 14 of its institutes and centers to better coordinate research done on the brain and nervous system. Neuroscience is “one of the most important and dynamic scientific frontiers for biomedical and behavioral research in this century,” said NIH Director Elias A. Zerhouni, M.D. “Greater synergy and cross-fertilization across research disciplines will be needed for progress in our understanding of this complex system and new discoveries of benefit to our patients.” The partnership blueprint will allow resources established by one institute or center to be open to scientists supported by other centers. The blueprint is available at

http://neuroscienceblueprint.nih.gov

Site for Parkinson's Trials Launched

A consortium comprising patient groups, private foundations, government, and industry has launched a new Web site dedicated to clinical trials for Parkinson's disease. The site,

www.pdtrials.org

Health Care Spending by the Elderly

U.S. seniors spent an average of $11,089 on personal health care goods and services in 1999, but nearly half that amount was reimbursed by Medicare and another 15% was paid for by Medicaid, according to a report prepared by the Centers for Medicare and Medicaid Services' Office of the Actuary. The amount spent by seniors was almost four times the average of $2,793 for people under age 65. “What this report shows is the importance of our efforts to bring down the high cost of health care for America's seniors,” CMS Administrator Mark B. McClellan, M.D., said in a statement. Although people 65 and over made up only 13% of the population in 1999, they accounted for 36% of personal health care spending, according to the report.

Improper Payments Increase

Medicare made about $20 billion in improper payments in fiscal year 2004, a report from the Centers for Medicare and Medicaid Services found. The sum included $900 million in underpayments to providers due to errors made by insurers and $20.8 billion in overpayments to providers. CMS hopes to cut the rate of erroneous payments more than half, to 4%, in 2008 by conducting more extensive payment reviews and other quality controls. “We have made significant strides in how we measure the error rate in Medicare payments, and that will enable us to do even more to bring it down,” said CMS Administrator Mark McClellan, M.D. A recent report from the Congressional Budget Office suggested that some of Medicaid's reimbursement policies may have contributed to increasing markups by pharmaceutical manufacturers.

Patients Turn to CAM

Discouraged by costly conventional treatments, 6 million Americans turned to alternative medicines in 2002 for chronic pain and other conditions, the Center for Studying Health System Change reported. These alternatives “may be of questionable value,” said HSC President Paul Ginsburg, Ph.D. About 63% of 31,000 adults said they used herbal remedies, yet two of the most popular remedies—St. John's wort and kava—can have serious side effects. The conventional medical professional was rarely aware of their patient using an alternative treatment.

Carotid Stent Guidelines Released

A coalition of groups has released a set of guidelines for determining when physicians are qualified to perform carotid artery stenting. “This is a very rigorous set of standards,” said Kenneth Rosenfield, M.D., director of cardiac and vascular invasive services at Massachusetts General Hospital in Boston. “This sets the bar very high.” The standards call for physicians to first be proficient in other types of stenting, and then to perform a minimum of 30 diagnostic angiograms and 25 carotid stenting procedures under supervision. They also call for physicians to be skilled in risk assessment, diagnosis, and alternative therapies for the patients involved, and to report and analyze their outcomes. The document notes that physicians of many different subspecialties will seek the training; one of the issues in developing the guidelines had been whether to restrict training only to certain specialists.

Neuroscience Partnership at NIH

The National Institutes of Health is breaking down barriers between 14 of its institutes and centers to better coordinate research done on the brain and nervous system. Neuroscience is “one of the most important and dynamic scientific frontiers for biomedical and behavioral research in this century,” said NIH Director Elias A. Zerhouni, M.D. “Greater synergy and cross-fertilization across research disciplines will be needed for progress in our understanding of this complex system and new discoveries of benefit to our patients.” The partnership blueprint will allow resources established by one institute or center to be open to scientists supported by other centers. The blueprint is available at

http://neuroscienceblueprint.nih.gov

Site for Parkinson's Trials Launched

A consortium comprising patient groups, private foundations, government, and industry has launched a new Web site dedicated to clinical trials for Parkinson's disease. The site,

www.pdtrials.org

Health Care Spending by the Elderly

U.S. seniors spent an average of $11,089 on personal health care goods and services in 1999, but nearly half that amount was reimbursed by Medicare and another 15% was paid for by Medicaid, according to a report prepared by the Centers for Medicare and Medicaid Services' Office of the Actuary. The amount spent by seniors was almost four times the average of $2,793 for people under age 65. “What this report shows is the importance of our efforts to bring down the high cost of health care for America's seniors,” CMS Administrator Mark B. McClellan, M.D., said in a statement. Although people 65 and over made up only 13% of the population in 1999, they accounted for 36% of personal health care spending, according to the report.

Improper Payments Increase

Medicare made about $20 billion in improper payments in fiscal year 2004, a report from the Centers for Medicare and Medicaid Services found. The sum included $900 million in underpayments to providers due to errors made by insurers and $20.8 billion in overpayments to providers. CMS hopes to cut the rate of erroneous payments more than half, to 4%, in 2008 by conducting more extensive payment reviews and other quality controls. “We have made significant strides in how we measure the error rate in Medicare payments, and that will enable us to do even more to bring it down,” said CMS Administrator Mark McClellan, M.D. A recent report from the Congressional Budget Office suggested that some of Medicaid's reimbursement policies may have contributed to increasing markups by pharmaceutical manufacturers.

Patients Turn to CAM

Discouraged by costly conventional treatments, 6 million Americans turned to alternative medicines in 2002 for chronic pain and other conditions, the Center for Studying Health System Change reported. These alternatives “may be of questionable value,” said HSC President Paul Ginsburg, Ph.D. About 63% of 31,000 adults said they used herbal remedies, yet two of the most popular remedies—St. John's wort and kava—can have serious side effects. The conventional medical professional was rarely aware of their patient using an alternative treatment.

Carotid Stent Guidelines Released

A coalition of groups has released a set of guidelines for determining when physicians are qualified to perform carotid artery stenting. “This is a very rigorous set of standards,” said Kenneth Rosenfield, M.D., director of cardiac and vascular invasive services at Massachusetts General Hospital in Boston. “This sets the bar very high.” The standards call for physicians to first be proficient in other types of stenting, and then to perform a minimum of 30 diagnostic angiograms and 25 carotid stenting procedures under supervision. They also call for physicians to be skilled in risk assessment, diagnosis, and alternative therapies for the patients involved, and to report and analyze their outcomes. The document notes that physicians of many different subspecialties will seek the training; one of the issues in developing the guidelines had been whether to restrict training only to certain specialists.

Neuroscience Partnership at NIH

The National Institutes of Health is breaking down barriers between 14 of its institutes and centers to better coordinate research done on the brain and nervous system. Neuroscience is “one of the most important and dynamic scientific frontiers for biomedical and behavioral research in this century,” said NIH Director Elias A. Zerhouni, M.D. “Greater synergy and cross-fertilization across research disciplines will be needed for progress in our understanding of this complex system and new discoveries of benefit to our patients.” The partnership blueprint will allow resources established by one institute or center to be open to scientists supported by other centers. The blueprint is available at

http://neuroscienceblueprint.nih.gov

Site for Parkinson's Trials Launched

A consortium comprising patient groups, private foundations, government, and industry has launched a new Web site dedicated to clinical trials for Parkinson's disease. The site,

www.pdtrials.org

Health Care Spending by the Elderly

U.S. seniors spent an average of $11,089 on personal health care goods and services in 1999, but nearly half that amount was reimbursed by Medicare and another 15% was paid for by Medicaid, according to a report prepared by the Centers for Medicare and Medicaid Services' Office of the Actuary. The amount spent by seniors was almost four times the average of $2,793 for people under age 65. “What this report shows is the importance of our efforts to bring down the high cost of health care for America's seniors,” CMS Administrator Mark B. McClellan, M.D., said in a statement. Although people 65 and over made up only 13% of the population in 1999, they accounted for 36% of personal health care spending, according to the report.

Improper Payments Increase

Medicare made about $20 billion in improper payments in fiscal year 2004, a report from the Centers for Medicare and Medicaid Services found. The sum included $900 million in underpayments to providers due to errors made by insurers and $20.8 billion in overpayments to providers. CMS hopes to cut the rate of erroneous payments more than half, to 4%, in 2008 by conducting more extensive payment reviews and other quality controls. “We have made significant strides in how we measure the error rate in Medicare payments, and that will enable us to do even more to bring it down,” said CMS Administrator Mark McClellan, M.D. A recent report from the Congressional Budget Office suggested that some of Medicaid's reimbursement policies may have contributed to increasing markups by pharmaceutical manufacturers.

Patients Turn to CAM

Discouraged by costly conventional treatments, 6 million Americans turned to alternative medicines in 2002 for chronic pain and other conditions, the Center for Studying Health System Change reported. These alternatives “may be of questionable value,” said HSC President Paul Ginsburg, Ph.D. About 63% of 31,000 adults said they used herbal remedies, yet two of the most popular remedies—St. John's wort and kava—can have serious side effects. The conventional medical professional was rarely aware of their patient using an alternative treatment.

BALTIMORE — The newest round of regulations implementing the Stark self-referral legislation has two provisions of particular interest to doctors: one on physician recruitment and the other on in-office ancillary services, several speakers said at a forum sponsored by the American Health Lawyers Association.

Physician recruitment “is clearly the biggest new exception,” said Kevin McAnaney, a lawyer in Washington. Under this phase of Stark II, which took effect in July, a hospital or federally qualified health center can pay to recruit a physician, provided that he or she is either a new physician or is relocating from outside the geographic area, defined as “the area comprised of the lowest number of contiguous zip codes from which the hospital draws at least 75% of its inpatients.”

The relocation provision applies to the doctors' offices, not their residences, and they must either move 25 or more miles away or have 75% new patients in their practice as a result of the move.

“Some people say that the only thing you have to do to meet the exception is meet one of the second two requirements—75% new patients or move 25 miles from the old location. [But] I think you have to move into the geographic service area and meet one of those tests,” he explained.

Baltimore lawyer Sanford Teplitzky agreed. “You have to recruit from outside the geographic area into the geographic area,” he said. For example, “the hospital can't get someone from outside and bring him to one of their satellite facilities that falls outside that [geographic area], even if there's a community need and a community benefit.”

Another important exception has to do with in-office ancillary services. Mr. McAnaney warned, however, that the exception applies to some services but it “does not cover most [durable medical equipment], enteral and parenteral nutrients, supplies, and equipment.”

He noted that under the regulation, “if the physician personally performs the services, it would not be [considered] a referral. What exactly that means remains to be fleshed out by [the Centers for Medicare and Medicaid Services], but I would not advise physicians to try to provide [durable medical equipment] personally.”

The language in the statute generally says that services eligible for the exception “are those which are integrally tied to the core practice of the physician,” Mr. Teplitzky said. “That's become fairly controversial. In some cases physicians have wanted to [include] things that normally they would never do, but would refer their patient to someone else for and they would provide the service or supplies and would bill for them.

“I believe this is an area that's going to be subject to some fair amount of scrutiny … of physicians who are trying to bring things into their practice that they would not ordinarily do, but they go out and hire a doctor as an independent contractor to come in so they could bill it through their service,” he continued.

To be eligible for the exception, the service also has to meet two other criteria, according to Mr. McAnaney:

▸ Supervision. “Basically, the service has to be performed by or supervised by the referring physician, another member of the group, or a physician in the group,” he said, noting that the supervision standard has been quite controversial in the past.

▸ Building. First, the building where the services are performed “has to be a [real structure]—no mobile equipment,” Mr. McAnaney said. Second, the services must be performed “in the same building where group practice is, basically has a full-time office there, open at least 35 hours per week, with the referring physician providing services 30 hours per week.”

If the physician practices in several offices and goes to a different one each day, “you could also provide services in the same building where the referring physician has an office that's open at least 8 hours per week and where the referring physician regularly practices there,” he continued.

Then there is the case where the practice has an office that's open 8 hours per week and a group physician regularly practices there at least 6 hours per week. But in that case, two additional tests must be met: The referring physician must be present to order the designated health services during the patient visit, or a group physician must actually be present when the designated health service is furnished.

On the billing side, “the requirement says services must be billed by the supervising physician, the group, or an entity 'wholly owned by such physician or group,'” Mr. McAnaney said. “The place where this sometimes raises some questions is there are more and more shared facilities or shared equipment in the same building. They still have to meet these requirements, so you have to make sure you can bill for the equipment and you meet those standards.”

BALTIMORE — The newest round of regulations implementing the Stark self-referral legislation has two provisions of particular interest to doctors: one on physician recruitment and the other on in-office ancillary services, several speakers said at a forum sponsored by the American Health Lawyers Association.

Physician recruitment “is clearly the biggest new exception,” said Kevin McAnaney, a lawyer in Washington. Under this phase of Stark II, which took effect in July, a hospital or federally qualified health center can pay to recruit a physician, provided that he or she is either a new physician or is relocating from outside the geographic area, defined as “the area comprised of the lowest number of contiguous zip codes from which the hospital draws at least 75% of its inpatients.”

The relocation provision applies to the doctors' offices, not their residences, and they must either move 25 or more miles away or have 75% new patients in their practice as a result of the move.

“Some people say that the only thing you have to do to meet the exception is meet one of the second two requirements—75% new patients or move 25 miles from the old location. [But] I think you have to move into the geographic service area and meet one of those tests,” he explained.

Baltimore lawyer Sanford Teplitzky agreed. “You have to recruit from outside the geographic area into the geographic area,” he said. For example, “the hospital can't get someone from outside and bring him to one of their satellite facilities that falls outside that [geographic area], even if there's a community need and a community benefit.”

Another important exception has to do with in-office ancillary services. Mr. McAnaney warned, however, that the exception applies to some services but it “does not cover most [durable medical equipment], enteral and parenteral nutrients, supplies, and equipment.”

He noted that under the regulation, “if the physician personally performs the services, it would not be [considered] a referral. What exactly that means remains to be fleshed out by [the Centers for Medicare and Medicaid Services], but I would not advise physicians to try to provide [durable medical equipment] personally.”

The language in the statute generally says that services eligible for the exception “are those which are integrally tied to the core practice of the physician,” Mr. Teplitzky said. “That's become fairly controversial. In some cases physicians have wanted to [include] things that normally they would never do, but would refer their patient to someone else for and they would provide the service or supplies and would bill for them.

“I believe this is an area that's going to be subject to some fair amount of scrutiny … of physicians who are trying to bring things into their practice that they would not ordinarily do, but they go out and hire a doctor as an independent contractor to come in so they could bill it through their service,” he continued.

To be eligible for the exception, the service also has to meet two other criteria, according to Mr. McAnaney:

▸ Supervision. “Basically, the service has to be performed by or supervised by the referring physician, another member of the group, or a physician in the group,” he said, noting that the supervision standard has been quite controversial in the past.

▸ Building. First, the building where the services are performed “has to be a [real structure]—no mobile equipment,” Mr. McAnaney said. Second, the services must be performed “in the same building where group practice is, basically has a full-time office there, open at least 35 hours per week, with the referring physician providing services 30 hours per week.”

If the physician practices in several offices and goes to a different one each day, “you could also provide services in the same building where the referring physician has an office that's open at least 8 hours per week and where the referring physician regularly practices there,” he continued.

Then there is the case where the practice has an office that's open 8 hours per week and a group physician regularly practices there at least 6 hours per week. But in that case, two additional tests must be met: The referring physician must be present to order the designated health services during the patient visit, or a group physician must actually be present when the designated health service is furnished.

On the billing side, “the requirement says services must be billed by the supervising physician, the group, or an entity 'wholly owned by such physician or group,'” Mr. McAnaney said. “The place where this sometimes raises some questions is there are more and more shared facilities or shared equipment in the same building. They still have to meet these requirements, so you have to make sure you can bill for the equipment and you meet those standards.”

BALTIMORE — The newest round of regulations implementing the Stark self-referral legislation has two provisions of particular interest to doctors: one on physician recruitment and the other on in-office ancillary services, several speakers said at a forum sponsored by the American Health Lawyers Association.

Physician recruitment “is clearly the biggest new exception,” said Kevin McAnaney, a lawyer in Washington. Under this phase of Stark II, which took effect in July, a hospital or federally qualified health center can pay to recruit a physician, provided that he or she is either a new physician or is relocating from outside the geographic area, defined as “the area comprised of the lowest number of contiguous zip codes from which the hospital draws at least 75% of its inpatients.”

The relocation provision applies to the doctors' offices, not their residences, and they must either move 25 or more miles away or have 75% new patients in their practice as a result of the move.

“Some people say that the only thing you have to do to meet the exception is meet one of the second two requirements—75% new patients or move 25 miles from the old location. [But] I think you have to move into the geographic service area and meet one of those tests,” he explained.

Baltimore lawyer Sanford Teplitzky agreed. “You have to recruit from outside the geographic area into the geographic area,” he said. For example, “the hospital can't get someone from outside and bring him to one of their satellite facilities that falls outside that [geographic area], even if there's a community need and a community benefit.”

Another important exception has to do with in-office ancillary services. Mr. McAnaney warned, however, that the exception applies to some services but it “does not cover most [durable medical equipment], enteral and parenteral nutrients, supplies, and equipment.”

He noted that under the regulation, “if the physician personally performs the services, it would not be [considered] a referral. What exactly that means remains to be fleshed out by [the Centers for Medicare and Medicaid Services], but I would not advise physicians to try to provide [durable medical equipment] personally.”

The language in the statute generally says that services eligible for the exception “are those which are integrally tied to the core practice of the physician,” Mr. Teplitzky said. “That's become fairly controversial. In some cases physicians have wanted to [include] things that normally they would never do, but would refer their patient to someone else for and they would provide the service or supplies and would bill for them.

“I believe this is an area that's going to be subject to some fair amount of scrutiny … of physicians who are trying to bring things into their practice that they would not ordinarily do, but they go out and hire a doctor as an independent contractor to come in so they could bill it through their service,” he continued.

To be eligible for the exception, the service also has to meet two other criteria, according to Mr. McAnaney:

▸ Supervision. “Basically, the service has to be performed by or supervised by the referring physician, another member of the group, or a physician in the group,” he said, noting that the supervision standard has been quite controversial in the past.

▸ Building. First, the building where the services are performed “has to be a [real structure]—no mobile equipment,” Mr. McAnaney said. Second, the services must be performed “in the same building where group practice is, basically has a full-time office there, open at least 35 hours per week, with the referring physician providing services 30 hours per week.”

If the physician practices in several offices and goes to a different one each day, “you could also provide services in the same building where the referring physician has an office that's open at least 8 hours per week and where the referring physician regularly practices there,” he continued.

Then there is the case where the practice has an office that's open 8 hours per week and a group physician regularly practices there at least 6 hours per week. But in that case, two additional tests must be met: The referring physician must be present to order the designated health services during the patient visit, or a group physician must actually be present when the designated health service is furnished.

On the billing side, “the requirement says services must be billed by the supervising physician, the group, or an entity 'wholly owned by such physician or group,'” Mr. McAnaney said. “The place where this sometimes raises some questions is there are more and more shared facilities or shared equipment in the same building. They still have to meet these requirements, so you have to make sure you can bill for the equipment and you meet those standards.”

WASHINGTON – Two years after the Government Accountability Office scolded Medicare for the inaccurate information its carrier call centers provided to physicians, a follow-up report finds that call-center performance has deteriorated even more.

In its February 2002 report, “Medicare: Communications With Physicians Can Be Improved,” the GAO noted that customer service representatives at Medicare carriers' call centers “rarely provided appropriate answers to questions, answering only 15% of our test calls completely and accurately.”

In a July 2004 report, the agency got right to the point: “Only 4% of the responses GAO received in 300 test calls to 34 call centers were correct and complete.”

In addition, the report noted, “[The Center for Medicare and Medicad Services'] efforts to provide oversight of carrier call centers are inadequate.” For instance, in 2002 the agency carried out only one evaluation of a carrier's telephone services; in 2003, there were none.

Stephanie Huff, government affairs analyst for the Medical Group Management Association (MGMA), said her organization was not surprised by the results. At MGMA, “we have two people specifically designated to deal with member calls, and a lot of time is spent sidestepping the call center process,” she said. “We will call CMS directly to get answers to questions our members have.”

The American Medical Association also agreed with the study results. “While the Medicare call centers' inability to correctly answer physicians' questions is troubling, sadly, it is not surprising,” Dr. J. James Rohack, chair of the AMA's board of trustees, said in a statement. “The GAO report confirms longstanding complaints from physicians about the lack of clear and reliable guidance on complex Medicare policy questions.”

The report's authors attributed the call centers' problems to a variety of factors, including:

▸ Fragmented information. “When responding to Medicare inquiries from providers, customer service representatives (CSRs) rely on fragments of information from multiple electronic sources,” such as both CMS and carrier Web sites, the report said. They also use various paper documents, including the Medicare carrier manual, program memorandums, carrier bulletins, and “printed Medicare program information, including policy changes, which CMS estimates at about 200 per year.”

For a question about billing for services delivered by therapy students, the CSRs who were contacted referred callers to 13 different documents. “Twelve of the references were either incorrect or did not include all of the information needed to give a correct and complete answer,” the report said. The 13th document was in a “Q and A” format, and it “included our specific test question but without the complete answer. Fragments of the answer, however, were located earlier in the document… It was evident to us that without reading the entire document, it would be plausible for the CSR to have read the test question and mistakenly given the caller the wrong answer, while assuming that the response given was correct and complete.”

▸ Difficulties in retaining CSRs. The report noted that an internal CMS study found the turnover rate for carrier call center CSRs to be as high as 23% from calendar years 1999 through 2001 for all of CMS's call centers. “This is significantly higher than the attrition rate for CMS's call centers for beneficiaries … which one CMS official estimates is close to industry standards–about 10%. Although there are no more recent data, CMS officials view this as troubling.”

CMS is currently trying out two initiatives to help CSRs, but neither of them is likely to help the representatives answer policy-oriented questions from providers, the report said. For instance, CMS has retained a consulting firm to write explanatory articles about new Medicare policies, but is not doing anything special to help CSRs get easy access to them.

“Although these articles contain citations to regulations and laws, for example, they are not electronically linked to the policies they describe,” the report noted. “In addition, the policies they support are not annotated to reflect that an article exists … Moreover, there are no plans to publish articles for the majority of existing policies.”

The report included several recommendations for improvement, including routinely screening and triaging calls by routing complex policy-oriented questions to staff with the expertise to adequately address them, developing clear and easily accessible policy-oriented materials to assist CSRs and making sure the materials are electronically searchable, and establishing an effective monitoring program for call centers to assess CSRs' performance.

Ms. Huff of MGMA applauded the recommendations. “The recommendations would be a quick and easy way for CMS to reduce its administrative burdens,” she said.

In its response to the GAO report, CMS generally agreed with the recommendations. For example, the agency said it “will soon issue a requirement that all call centers create a tiered approach to answering provider inquiries.” That approach, which CMS hopes also will help with retention by creating opportunities for promotion, is expected to begin in fiscal year 2005.

WASHINGTON – Two years after the Government Accountability Office scolded Medicare for the inaccurate information its carrier call centers provided to physicians, a follow-up report finds that call-center performance has deteriorated even more.

In its February 2002 report, “Medicare: Communications With Physicians Can Be Improved,” the GAO noted that customer service representatives at Medicare carriers' call centers “rarely provided appropriate answers to questions, answering only 15% of our test calls completely and accurately.”

In a July 2004 report, the agency got right to the point: “Only 4% of the responses GAO received in 300 test calls to 34 call centers were correct and complete.”

In addition, the report noted, “[The Center for Medicare and Medicad Services'] efforts to provide oversight of carrier call centers are inadequate.” For instance, in 2002 the agency carried out only one evaluation of a carrier's telephone services; in 2003, there were none.

Stephanie Huff, government affairs analyst for the Medical Group Management Association (MGMA), said her organization was not surprised by the results. At MGMA, “we have two people specifically designated to deal with member calls, and a lot of time is spent sidestepping the call center process,” she said. “We will call CMS directly to get answers to questions our members have.”

The American Medical Association also agreed with the study results. “While the Medicare call centers' inability to correctly answer physicians' questions is troubling, sadly, it is not surprising,” Dr. J. James Rohack, chair of the AMA's board of trustees, said in a statement. “The GAO report confirms longstanding complaints from physicians about the lack of clear and reliable guidance on complex Medicare policy questions.”

The report's authors attributed the call centers' problems to a variety of factors, including:

▸ Fragmented information. “When responding to Medicare inquiries from providers, customer service representatives (CSRs) rely on fragments of information from multiple electronic sources,” such as both CMS and carrier Web sites, the report said. They also use various paper documents, including the Medicare carrier manual, program memorandums, carrier bulletins, and “printed Medicare program information, including policy changes, which CMS estimates at about 200 per year.”

For a question about billing for services delivered by therapy students, the CSRs who were contacted referred callers to 13 different documents. “Twelve of the references were either incorrect or did not include all of the information needed to give a correct and complete answer,” the report said. The 13th document was in a “Q and A” format, and it “included our specific test question but without the complete answer. Fragments of the answer, however, were located earlier in the document… It was evident to us that without reading the entire document, it would be plausible for the CSR to have read the test question and mistakenly given the caller the wrong answer, while assuming that the response given was correct and complete.”

▸ Difficulties in retaining CSRs. The report noted that an internal CMS study found the turnover rate for carrier call center CSRs to be as high as 23% from calendar years 1999 through 2001 for all of CMS's call centers. “This is significantly higher than the attrition rate for CMS's call centers for beneficiaries … which one CMS official estimates is close to industry standards–about 10%. Although there are no more recent data, CMS officials view this as troubling.”

CMS is currently trying out two initiatives to help CSRs, but neither of them is likely to help the representatives answer policy-oriented questions from providers, the report said. For instance, CMS has retained a consulting firm to write explanatory articles about new Medicare policies, but is not doing anything special to help CSRs get easy access to them.

“Although these articles contain citations to regulations and laws, for example, they are not electronically linked to the policies they describe,” the report noted. “In addition, the policies they support are not annotated to reflect that an article exists … Moreover, there are no plans to publish articles for the majority of existing policies.”

The report included several recommendations for improvement, including routinely screening and triaging calls by routing complex policy-oriented questions to staff with the expertise to adequately address them, developing clear and easily accessible policy-oriented materials to assist CSRs and making sure the materials are electronically searchable, and establishing an effective monitoring program for call centers to assess CSRs' performance.

Ms. Huff of MGMA applauded the recommendations. “The recommendations would be a quick and easy way for CMS to reduce its administrative burdens,” she said.

In its response to the GAO report, CMS generally agreed with the recommendations. For example, the agency said it “will soon issue a requirement that all call centers create a tiered approach to answering provider inquiries.” That approach, which CMS hopes also will help with retention by creating opportunities for promotion, is expected to begin in fiscal year 2005.

WASHINGTON – Two years after the Government Accountability Office scolded Medicare for the inaccurate information its carrier call centers provided to physicians, a follow-up report finds that call-center performance has deteriorated even more.

In its February 2002 report, “Medicare: Communications With Physicians Can Be Improved,” the GAO noted that customer service representatives at Medicare carriers' call centers “rarely provided appropriate answers to questions, answering only 15% of our test calls completely and accurately.”

In a July 2004 report, the agency got right to the point: “Only 4% of the responses GAO received in 300 test calls to 34 call centers were correct and complete.”

In addition, the report noted, “[The Center for Medicare and Medicad Services'] efforts to provide oversight of carrier call centers are inadequate.” For instance, in 2002 the agency carried out only one evaluation of a carrier's telephone services; in 2003, there were none.

Stephanie Huff, government affairs analyst for the Medical Group Management Association (MGMA), said her organization was not surprised by the results. At MGMA, “we have two people specifically designated to deal with member calls, and a lot of time is spent sidestepping the call center process,” she said. “We will call CMS directly to get answers to questions our members have.”

The American Medical Association also agreed with the study results. “While the Medicare call centers' inability to correctly answer physicians' questions is troubling, sadly, it is not surprising,” Dr. J. James Rohack, chair of the AMA's board of trustees, said in a statement. “The GAO report confirms longstanding complaints from physicians about the lack of clear and reliable guidance on complex Medicare policy questions.”

The report's authors attributed the call centers' problems to a variety of factors, including:

▸ Fragmented information. “When responding to Medicare inquiries from providers, customer service representatives (CSRs) rely on fragments of information from multiple electronic sources,” such as both CMS and carrier Web sites, the report said. They also use various paper documents, including the Medicare carrier manual, program memorandums, carrier bulletins, and “printed Medicare program information, including policy changes, which CMS estimates at about 200 per year.”

For a question about billing for services delivered by therapy students, the CSRs who were contacted referred callers to 13 different documents. “Twelve of the references were either incorrect or did not include all of the information needed to give a correct and complete answer,” the report said. The 13th document was in a “Q and A” format, and it “included our specific test question but without the complete answer. Fragments of the answer, however, were located earlier in the document… It was evident to us that without reading the entire document, it would be plausible for the CSR to have read the test question and mistakenly given the caller the wrong answer, while assuming that the response given was correct and complete.”

▸ Difficulties in retaining CSRs. The report noted that an internal CMS study found the turnover rate for carrier call center CSRs to be as high as 23% from calendar years 1999 through 2001 for all of CMS's call centers. “This is significantly higher than the attrition rate for CMS's call centers for beneficiaries … which one CMS official estimates is close to industry standards–about 10%. Although there are no more recent data, CMS officials view this as troubling.”

CMS is currently trying out two initiatives to help CSRs, but neither of them is likely to help the representatives answer policy-oriented questions from providers, the report said. For instance, CMS has retained a consulting firm to write explanatory articles about new Medicare policies, but is not doing anything special to help CSRs get easy access to them.

“Although these articles contain citations to regulations and laws, for example, they are not electronically linked to the policies they describe,” the report noted. “In addition, the policies they support are not annotated to reflect that an article exists … Moreover, there are no plans to publish articles for the majority of existing policies.”

The report included several recommendations for improvement, including routinely screening and triaging calls by routing complex policy-oriented questions to staff with the expertise to adequately address them, developing clear and easily accessible policy-oriented materials to assist CSRs and making sure the materials are electronically searchable, and establishing an effective monitoring program for call centers to assess CSRs' performance.

Ms. Huff of MGMA applauded the recommendations. “The recommendations would be a quick and easy way for CMS to reduce its administrative burdens,” she said.

In its response to the GAO report, CMS generally agreed with the recommendations. For example, the agency said it “will soon issue a requirement that all call centers create a tiered approach to answering provider inquiries.” That approach, which CMS hopes also will help with retention by creating opportunities for promotion, is expected to begin in fiscal year 2005.

Depression Treatment for Men

Improving primary care treatment for depression might help narrow the “gender gap” that leaves a greater proportion of depressed men untreated, according to a study from the Rand Corp. The researchers assigned 46 primary care practices nationwide to either usual care for depression or to improvement programs that educated providers and patients about depression treatment. Among the practices that participated in an improvement program, the rates of depression treatment increased for both sexes, but some treatment approaches increased care for men more than for women. “The findings suggest that quality improvement programs may help reduce the treatment disparity seen among the estimated 6 million depressed men in the United States,” the researchers reported.

Teens Delaying Sexual Activity

Sexual activity among younger teenagers declined significantly between 1995 and 2002, while use of contraception increased, according to a study by the Centers for Disease Control and Prevention. Among never-married girls aged 15-17 years, 30% of those surveyed in 2002 had ever had intercourse, compared with 38% in 1995. Among boys the same age, the percentage dropped from 43% in 1995 to 31% in 2002. The numbers were more mixed among adolescents aged 18-19; the percentage of boys in that group who had ever had sex dropped from 75% to 64%, but the percentage among the girls actually went from 68% to 69%. More than three-quarters used contraception when they began having intercourse. “More teenagers are avoiding or postponing sexual activity, which can lead to sexually transmitted diseases, unwanted pregnancy, or emotional and societal responsibilities for which they are not prepared,” the Health and Human Services Department reported in a statement.

Doctors Bilked in Insurance Scam

The U.S. Department of Justice has frozen over $500 million in bank and investment accounts that department officials say represent booty from a fraudulent tax avoidance scheme. The department issued a temporary restraining order against xélan Inc. and related entities. Federal officials alleged that the company, based in San Diego, advised thousands of doctors and other medical professionals to place their income in various tax schemes involving supposed “supplemental insurance products” or improper charitable deductions. The Internal Revenue Service estimates that the 4,000 doctors who participated may owe as much as $420 million in taxes, interest, and penalties. A temporary receiver has been named to guard assets and handle claims; doctors who want to file a claim or get information on the case should contact the receiver, William “Biff” Leonard, at

[email protected]

Group Pays $1.9 Million Settlement

Temple University Physicians has agreed to pay almost $1.9 million to settle civil charges arising from an investigation into the group's Medicare Part B billing practices. The Department of Health and Human Services audited Medicare Part B claims submitted by the group between July 1995 and July 1996 and concluded that the group lacked sufficient documentation to support some claims, and that some of the claims represented a greater level of service than was actually provided. “Through this settlement we are protecting the integrity of the Medicare system on which our senior citizens depend for their critical health care coverage,” Patrick Meehan, U.S. Attorney for the Eastern District of Pennsylvania, said in a statement on behalf of HHS. Temple University Physicians denies both the government's allegations and any liability relating to them.

Health Care Spending by Elderly

U.S. seniors spent an average of $11,089 on personal health care goods and services in 1999, but nearly half of that amount was reimbursed by Medicare and another 15% was paid for by Medicaid, according to a report prepared by the Centers for Medicare and Medicaid Services' Office of the Actuary. The amount spent by seniors was almost four times the average of $2,793 for people under age 65 years. “What this report shows is the importance of our efforts to bring down the high cost of health care for America's seniors,” CMS Administrator Mark B. McClellan, M.D., said in a statement. Although people aged 65 and over made up only 13% of the population in 1999, they accounted for 36% of personal health care spending, according to the report. On the other hand, children made up 29% of the population but accounted only for 12% of personal health care spending.

Medicaid Overcharged for Drugs

The Medicaid program is being overcharged for prescription drugs, George M. Reeb, assistant inspector general for the Centers for Medicare and Medicaid Audits at the Department of Health and Human Services, said in recent testimony to a House Energy and Commerce subcommittee. Part of the problem is that states vary greatly in the reimbursement amounts they set for prescription drugs. For example, “based on state data, we estimated that, overall, Medicaid could have saved as much as $86.7 million in fiscal year 2001 if all 42 states had reimbursed at the same price as the lowest paying state for each of the drugs reviewed,” Mr. Reeb said in his testimony. He recommended that states get better access to accurate wholesale pricing information and adopt other strategies to contain costs.

Depression Treatment for Men

Improving primary care treatment for depression might help narrow the “gender gap” that leaves a greater proportion of depressed men untreated, according to a study from the Rand Corp. The researchers assigned 46 primary care practices nationwide to either usual care for depression or to improvement programs that educated providers and patients about depression treatment. Among the practices that participated in an improvement program, the rates of depression treatment increased for both sexes, but some treatment approaches increased care for men more than for women. “The findings suggest that quality improvement programs may help reduce the treatment disparity seen among the estimated 6 million depressed men in the United States,” the researchers reported.

Teens Delaying Sexual Activity

Sexual activity among younger teenagers declined significantly between 1995 and 2002, while use of contraception increased, according to a study by the Centers for Disease Control and Prevention. Among never-married girls aged 15-17 years, 30% of those surveyed in 2002 had ever had intercourse, compared with 38% in 1995. Among boys the same age, the percentage dropped from 43% in 1995 to 31% in 2002. The numbers were more mixed among adolescents aged 18-19; the percentage of boys in that group who had ever had sex dropped from 75% to 64%, but the percentage among the girls actually went from 68% to 69%. More than three-quarters used contraception when they began having intercourse. “More teenagers are avoiding or postponing sexual activity, which can lead to sexually transmitted diseases, unwanted pregnancy, or emotional and societal responsibilities for which they are not prepared,” the Health and Human Services Department reported in a statement.

Doctors Bilked in Insurance Scam

The U.S. Department of Justice has frozen over $500 million in bank and investment accounts that department officials say represent booty from a fraudulent tax avoidance scheme. The department issued a temporary restraining order against xélan Inc. and related entities. Federal officials alleged that the company, based in San Diego, advised thousands of doctors and other medical professionals to place their income in various tax schemes involving supposed “supplemental insurance products” or improper charitable deductions. The Internal Revenue Service estimates that the 4,000 doctors who participated may owe as much as $420 million in taxes, interest, and penalties. A temporary receiver has been named to guard assets and handle claims; doctors who want to file a claim or get information on the case should contact the receiver, William “Biff” Leonard, at

[email protected]

Group Pays $1.9 Million Settlement

Temple University Physicians has agreed to pay almost $1.9 million to settle civil charges arising from an investigation into the group's Medicare Part B billing practices. The Department of Health and Human Services audited Medicare Part B claims submitted by the group between July 1995 and July 1996 and concluded that the group lacked sufficient documentation to support some claims, and that some of the claims represented a greater level of service than was actually provided. “Through this settlement we are protecting the integrity of the Medicare system on which our senior citizens depend for their critical health care coverage,” Patrick Meehan, U.S. Attorney for the Eastern District of Pennsylvania, said in a statement on behalf of HHS. Temple University Physicians denies both the government's allegations and any liability relating to them.

Health Care Spending by Elderly

U.S. seniors spent an average of $11,089 on personal health care goods and services in 1999, but nearly half of that amount was reimbursed by Medicare and another 15% was paid for by Medicaid, according to a report prepared by the Centers for Medicare and Medicaid Services' Office of the Actuary. The amount spent by seniors was almost four times the average of $2,793 for people under age 65 years. “What this report shows is the importance of our efforts to bring down the high cost of health care for America's seniors,” CMS Administrator Mark B. McClellan, M.D., said in a statement. Although people aged 65 and over made up only 13% of the population in 1999, they accounted for 36% of personal health care spending, according to the report. On the other hand, children made up 29% of the population but accounted only for 12% of personal health care spending.

Medicaid Overcharged for Drugs

The Medicaid program is being overcharged for prescription drugs, George M. Reeb, assistant inspector general for the Centers for Medicare and Medicaid Audits at the Department of Health and Human Services, said in recent testimony to a House Energy and Commerce subcommittee. Part of the problem is that states vary greatly in the reimbursement amounts they set for prescription drugs. For example, “based on state data, we estimated that, overall, Medicaid could have saved as much as $86.7 million in fiscal year 2001 if all 42 states had reimbursed at the same price as the lowest paying state for each of the drugs reviewed,” Mr. Reeb said in his testimony. He recommended that states get better access to accurate wholesale pricing information and adopt other strategies to contain costs.

Depression Treatment for Men

Improving primary care treatment for depression might help narrow the “gender gap” that leaves a greater proportion of depressed men untreated, according to a study from the Rand Corp. The researchers assigned 46 primary care practices nationwide to either usual care for depression or to improvement programs that educated providers and patients about depression treatment. Among the practices that participated in an improvement program, the rates of depression treatment increased for both sexes, but some treatment approaches increased care for men more than for women. “The findings suggest that quality improvement programs may help reduce the treatment disparity seen among the estimated 6 million depressed men in the United States,” the researchers reported.

Teens Delaying Sexual Activity

Sexual activity among younger teenagers declined significantly between 1995 and 2002, while use of contraception increased, according to a study by the Centers for Disease Control and Prevention. Among never-married girls aged 15-17 years, 30% of those surveyed in 2002 had ever had intercourse, compared with 38% in 1995. Among boys the same age, the percentage dropped from 43% in 1995 to 31% in 2002. The numbers were more mixed among adolescents aged 18-19; the percentage of boys in that group who had ever had sex dropped from 75% to 64%, but the percentage among the girls actually went from 68% to 69%. More than three-quarters used contraception when they began having intercourse. “More teenagers are avoiding or postponing sexual activity, which can lead to sexually transmitted diseases, unwanted pregnancy, or emotional and societal responsibilities for which they are not prepared,” the Health and Human Services Department reported in a statement.

Doctors Bilked in Insurance Scam

The U.S. Department of Justice has frozen over $500 million in bank and investment accounts that department officials say represent booty from a fraudulent tax avoidance scheme. The department issued a temporary restraining order against xélan Inc. and related entities. Federal officials alleged that the company, based in San Diego, advised thousands of doctors and other medical professionals to place their income in various tax schemes involving supposed “supplemental insurance products” or improper charitable deductions. The Internal Revenue Service estimates that the 4,000 doctors who participated may owe as much as $420 million in taxes, interest, and penalties. A temporary receiver has been named to guard assets and handle claims; doctors who want to file a claim or get information on the case should contact the receiver, William “Biff” Leonard, at

[email protected]

Group Pays $1.9 Million Settlement

Temple University Physicians has agreed to pay almost $1.9 million to settle civil charges arising from an investigation into the group's Medicare Part B billing practices. The Department of Health and Human Services audited Medicare Part B claims submitted by the group between July 1995 and July 1996 and concluded that the group lacked sufficient documentation to support some claims, and that some of the claims represented a greater level of service than was actually provided. “Through this settlement we are protecting the integrity of the Medicare system on which our senior citizens depend for their critical health care coverage,” Patrick Meehan, U.S. Attorney for the Eastern District of Pennsylvania, said in a statement on behalf of HHS. Temple University Physicians denies both the government's allegations and any liability relating to them.

Health Care Spending by Elderly

U.S. seniors spent an average of $11,089 on personal health care goods and services in 1999, but nearly half of that amount was reimbursed by Medicare and another 15% was paid for by Medicaid, according to a report prepared by the Centers for Medicare and Medicaid Services' Office of the Actuary. The amount spent by seniors was almost four times the average of $2,793 for people under age 65 years. “What this report shows is the importance of our efforts to bring down the high cost of health care for America's seniors,” CMS Administrator Mark B. McClellan, M.D., said in a statement. Although people aged 65 and over made up only 13% of the population in 1999, they accounted for 36% of personal health care spending, according to the report. On the other hand, children made up 29% of the population but accounted only for 12% of personal health care spending.

Medicaid Overcharged for Drugs

The Medicaid program is being overcharged for prescription drugs, George M. Reeb, assistant inspector general for the Centers for Medicare and Medicaid Audits at the Department of Health and Human Services, said in recent testimony to a House Energy and Commerce subcommittee. Part of the problem is that states vary greatly in the reimbursement amounts they set for prescription drugs. For example, “based on state data, we estimated that, overall, Medicaid could have saved as much as $86.7 million in fiscal year 2001 if all 42 states had reimbursed at the same price as the lowest paying state for each of the drugs reviewed,” Mr. Reeb said in his testimony. He recommended that states get better access to accurate wholesale pricing information and adopt other strategies to contain costs.