Medicolegal Issues

Clinical question: What is the relationship between duration of intravenous (IV) antibiotic therapy and treatment failure in infants <6 months of age hospitalized with urinary tract infections (UTIs)?

Background: There is an inadequate evidence base to drive decisions regarding duration of IV antibiotic therapy in young infants hospitalized with UTIs. Documented variability exists in length of stay (LOS) and resource utilization for these infants, which might be a direct result of practice variation with respect to IV therapy.

Study design: Retrospective cohort study.

Setting: Twenty-four freestanding children’s hospitals.

Synopsis: The Pediatric Health Information System (PHIS) administrative database was used to identify healthy infants <6 months of age admitted with a primary or secondary diagnosis of UTI or pyelonephritis from 1999 to 2004 to participating hospitals. Duration of IV therapy was defined as a dichotomous variable with three days (short course: three days) selected because it was the median length of therapy. Treatment failure was defined as readmission within 30 days.

More than 12,300 records were analyzed. Male gender, neonatal status, black race, Hispanic ethnicity, nonprivate insurance, severity of illness, known bacteremia, known genitourinary tract disorders, and specific hospital were independently associated with increased likelihood of long-course (four days) therapy.

Unadjusted analysis initially revealed that long-course therapy was significantly associated with a higher rate of treatment failure. After multivariate (to include propensity scores) adjustment, a significant association between treatment duration and failure was no longer identified. Treatment failure association with known genitourinary abnormalities and higher severity of illness remained.

A significant limitation of this study is the potential for multivariate analysis to fail to mitigate a bias toward sicker patients receiving longer duration of antibiotic therapy and, thus, having a higher likelihood of treatment failure. In addition, the greater question of when IV antibiotics (and hospital admission) are indicated in this population was not addressed by the study design.

Nonetheless, the data likely support a limited utility to long-course IV antibiotic therapy in this population. The study also adds to the evolving picture of considerable and widespread variation in physician practice.

Bottom line: Short-course IV therapy for infants with UTIs does not increase risk of treatment failure.

Citation: Brady PW, Conway PH, Goudie A. Length of intravenous antibiotic therapy and treatment failure in infants with urinary tract infections. Pediatrics. 2010;126(2):196-203.

Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the relationship between duration of intravenous (IV) antibiotic therapy and treatment failure in infants <6 months of age hospitalized with urinary tract infections (UTIs)?

Background: There is an inadequate evidence base to drive decisions regarding duration of IV antibiotic therapy in young infants hospitalized with UTIs. Documented variability exists in length of stay (LOS) and resource utilization for these infants, which might be a direct result of practice variation with respect to IV therapy.

Study design: Retrospective cohort study.

Setting: Twenty-four freestanding children’s hospitals.

Synopsis: The Pediatric Health Information System (PHIS) administrative database was used to identify healthy infants <6 months of age admitted with a primary or secondary diagnosis of UTI or pyelonephritis from 1999 to 2004 to participating hospitals. Duration of IV therapy was defined as a dichotomous variable with three days (short course: three days) selected because it was the median length of therapy. Treatment failure was defined as readmission within 30 days.

More than 12,300 records were analyzed. Male gender, neonatal status, black race, Hispanic ethnicity, nonprivate insurance, severity of illness, known bacteremia, known genitourinary tract disorders, and specific hospital were independently associated with increased likelihood of long-course (four days) therapy.

Unadjusted analysis initially revealed that long-course therapy was significantly associated with a higher rate of treatment failure. After multivariate (to include propensity scores) adjustment, a significant association between treatment duration and failure was no longer identified. Treatment failure association with known genitourinary abnormalities and higher severity of illness remained.

A significant limitation of this study is the potential for multivariate analysis to fail to mitigate a bias toward sicker patients receiving longer duration of antibiotic therapy and, thus, having a higher likelihood of treatment failure. In addition, the greater question of when IV antibiotics (and hospital admission) are indicated in this population was not addressed by the study design.

Nonetheless, the data likely support a limited utility to long-course IV antibiotic therapy in this population. The study also adds to the evolving picture of considerable and widespread variation in physician practice.

Bottom line: Short-course IV therapy for infants with UTIs does not increase risk of treatment failure.

Citation: Brady PW, Conway PH, Goudie A. Length of intravenous antibiotic therapy and treatment failure in infants with urinary tract infections. Pediatrics. 2010;126(2):196-203.

Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the relationship between duration of intravenous (IV) antibiotic therapy and treatment failure in infants <6 months of age hospitalized with urinary tract infections (UTIs)?

Background: There is an inadequate evidence base to drive decisions regarding duration of IV antibiotic therapy in young infants hospitalized with UTIs. Documented variability exists in length of stay (LOS) and resource utilization for these infants, which might be a direct result of practice variation with respect to IV therapy.

Study design: Retrospective cohort study.

Setting: Twenty-four freestanding children’s hospitals.

Synopsis: The Pediatric Health Information System (PHIS) administrative database was used to identify healthy infants <6 months of age admitted with a primary or secondary diagnosis of UTI or pyelonephritis from 1999 to 2004 to participating hospitals. Duration of IV therapy was defined as a dichotomous variable with three days (short course: three days) selected because it was the median length of therapy. Treatment failure was defined as readmission within 30 days.

More than 12,300 records were analyzed. Male gender, neonatal status, black race, Hispanic ethnicity, nonprivate insurance, severity of illness, known bacteremia, known genitourinary tract disorders, and specific hospital were independently associated with increased likelihood of long-course (four days) therapy.

Unadjusted analysis initially revealed that long-course therapy was significantly associated with a higher rate of treatment failure. After multivariate (to include propensity scores) adjustment, a significant association between treatment duration and failure was no longer identified. Treatment failure association with known genitourinary abnormalities and higher severity of illness remained.

A significant limitation of this study is the potential for multivariate analysis to fail to mitigate a bias toward sicker patients receiving longer duration of antibiotic therapy and, thus, having a higher likelihood of treatment failure. In addition, the greater question of when IV antibiotics (and hospital admission) are indicated in this population was not addressed by the study design.

Nonetheless, the data likely support a limited utility to long-course IV antibiotic therapy in this population. The study also adds to the evolving picture of considerable and widespread variation in physician practice.

Bottom line: Short-course IV therapy for infants with UTIs does not increase risk of treatment failure.

Citation: Brady PW, Conway PH, Goudie A. Length of intravenous antibiotic therapy and treatment failure in infants with urinary tract infections. Pediatrics. 2010;126(2):196-203.

Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Recent media reports about the dangers surrounding unused prescription medications, including abuse by teens and medications finding their way into the water supply, have prompted an increase in inquiries to healthcare providers about disposing of unused medication. These issues are complicated when controlled substances are involved.

Often, providers are unsure how to respond to patient questions about medication disposal. For example, what would you do if a patient requests an alternative medication because of an unwanted side effect and brings the originally prescribed medication back to you? What if the family of a recently expired patient brings unused medication to you and asks you to donate it to other patients? What if you have a colleague who performs mission work; could you accept and donate unused medication for use in another country?

Unfortunately, the Controlled Substances Act (CSA) does not provide a readily available mechanism to accomplish efficient, secure, and environmentally sound methods to collect and use or dispose of unwanted controlled substances. This article explains the rules physicians must adhere to and guidelines for “taking back” controlled substances.

The Legislation

Enacted in 1970, the CSA combined all existing federal drug laws into a single statute. It created five “schedules” in which certain drugs are classified. These “scheduled” drugs are commonly referred to as controlled substances. A drug’s classification depends on its potential for abuse and its currently accepted medical use in the U.S. Additionally, provisions of international treaties impact classification.

Under the classification system, Schedule I drugs have a high potential for abuse and have no currently accepted medical use in treatment in the U.S. In contrast, Schedule V drugs have a low potential for abuse and do have a currently accepted medical use in treatment in the U.S.

The CSA governs the manufacture, import, export, possession, use, and distribution of controlled substances. In doing so, the CSA established a system to register those authorized to handle controlled substances. Manufacturers, dispensers, distributors, and individual practitioners who prescribe controlled substances must be registered with the Drug Enforcement Administration (DEA).

The CSA requires registrants to keep certain records for at least two years related to their handling of controlled substances. For example, physician registrants must keep records of controlled substances in Schedules II, III, IV, and V that are dispensed via methods other than prescribing or administering (e.g., industry samples). Inventories of controlled substances are required. Most notably, physicians generally are not required to keep records of prescribed medications; however, records must be kept if drugs are dispensed or administered. Moreover, there are heightened recordkeeping responsibilities for providers who prescribe, dispense, or administer for maintenance or detoxification.

Controlled Substance “Takeback”

The system of registration established by the CSA prohibits a DEA registrant from acquiring controlled substances from nonregistered entities and, in turn, bars an end-user from distributing pharmaceutical controlled substances to a DEA registrant. In other words, physicians cannot receive controlled substances from anyone who does not also have a registration. Thus, physicians may not “take back” prescribed medications from patients or their family members. Similarly, except in cases of a drug being recalled or a dispensing error, patients are not allowed to return controlled medications to a pharmacy.

Information on how a patient or family member should properly dispose of medication is commonly misunderstood. DEA regulations provide a process for nonregistrants to dispose of unused medication; however, it is cumbersome and meant to be used only when dealing with large quantities of controlled substances (e.g., large quantities of abandoned drugs). In such cases, the DEA special agent in charge (SAC) may instruct on disposal, which may include transfer of the substance to a DEA registrant, delivery to a DEA agent or office, destruction in the presence of an agent of the administration or other authorized person, or by other means. The person must submit a letter to the local SAC, which includes:

• Name and address of the person;
• Name and quantity of each controlled substance to be disposed of;
• Explanation of how the applicant obtained the controlled substance, if known; and
• Name, address, and registration number, if known, of the person who possessed the controlled substances prior to the applicant.

Federal legislation also provides a way for the DEA to grant approval to law-enforcement agencies to operate “takeback” programs. The regulation states that “any person in possession of a controlled substance and desiring to dispose of such substance may request assistance from the SAC in the area in which the person is located.” The regulation allows the SAC to authorize and specify the means of disposal to assure that the controlled substances do not become available to unauthorized persons.

State and local government agencies and community associations might hold takeback programs only if law enforcement makes the request, takes custody of the controlled substances, and is responsible for the disposal.

The U.S. Office of National Drug Control Policy has published guidelines for medication disposal. These guidelines advise flushing medications only if the prescription label or accompanying patient information specifically states to do so. Instead of flushing, the guidelines recommend that medications be disposed of through a takeback program or by:

• Taking the prescription drugs out of their original containers;
• Mixing the drugs with an undesirable substance, such as cat litter or used coffee grounds;
• Placing the mixture into a disposable container with a lid, such as an empty margarine tub, or into a sealable bag;
• Concealing or removing personal information, including Rx number, on the empty containers by covering it with black permanent marker or duct tape, or by scratching it off; and
• Placing the sealed container with the mixture, and the empty drug containers, in the trash.

Unused Medication Donation

The rising cost of prescription medication leaves many questioning whether there is a need for a safe method to allow unused medication to be donated to others. At least 10 states have passed laws allowing or encouraging the donation of unused pharmaceutical drugs. Many of these programs involve healthcare facilities, nursing homes, or pharmacies. The CSA and current DEA regulations, however, prohibit patients from delivering or distributing controlled substances to a DEA registrant, even if it is for the purpose of a donation. Moreover, the Food and Drug Administration (FDA) does not permit redistribution of medications, except under limited circumstances.

Consequently, state law may be inconsistent with federal law for donation and reuse of controlled substances.

Conclusion

Physicians who fail to comply with CSA handling requirements are subject to criminal charges, discipline against their DEA registration, and discipline against their license to practice medicine. Consequently, physicians should use caution whenever handling unused medication.

The application of various aspects of the CSA and implementing rules is situation-specific. Moreover, the DEA may issue additional regulations. Accordingly, if you have a question about a specific situation, consult an attorney, or contact your local DEA field division office and ask for the diversion duty agent. TH

Patrick O’Rourke works in the Office of University Counsel, Department of Litigation, University of Colorado Denver.

Recent media reports about the dangers surrounding unused prescription medications, including abuse by teens and medications finding their way into the water supply, have prompted an increase in inquiries to healthcare providers about disposing of unused medication. These issues are complicated when controlled substances are involved.

Often, providers are unsure how to respond to patient questions about medication disposal. For example, what would you do if a patient requests an alternative medication because of an unwanted side effect and brings the originally prescribed medication back to you? What if the family of a recently expired patient brings unused medication to you and asks you to donate it to other patients? What if you have a colleague who performs mission work; could you accept and donate unused medication for use in another country?

Unfortunately, the Controlled Substances Act (CSA) does not provide a readily available mechanism to accomplish efficient, secure, and environmentally sound methods to collect and use or dispose of unwanted controlled substances. This article explains the rules physicians must adhere to and guidelines for “taking back” controlled substances.

The Legislation

Enacted in 1970, the CSA combined all existing federal drug laws into a single statute. It created five “schedules” in which certain drugs are classified. These “scheduled” drugs are commonly referred to as controlled substances. A drug’s classification depends on its potential for abuse and its currently accepted medical use in the U.S. Additionally, provisions of international treaties impact classification.

Under the classification system, Schedule I drugs have a high potential for abuse and have no currently accepted medical use in treatment in the U.S. In contrast, Schedule V drugs have a low potential for abuse and do have a currently accepted medical use in treatment in the U.S.

The CSA governs the manufacture, import, export, possession, use, and distribution of controlled substances. In doing so, the CSA established a system to register those authorized to handle controlled substances. Manufacturers, dispensers, distributors, and individual practitioners who prescribe controlled substances must be registered with the Drug Enforcement Administration (DEA).

The CSA requires registrants to keep certain records for at least two years related to their handling of controlled substances. For example, physician registrants must keep records of controlled substances in Schedules II, III, IV, and V that are dispensed via methods other than prescribing or administering (e.g., industry samples). Inventories of controlled substances are required. Most notably, physicians generally are not required to keep records of prescribed medications; however, records must be kept if drugs are dispensed or administered. Moreover, there are heightened recordkeeping responsibilities for providers who prescribe, dispense, or administer for maintenance or detoxification.

Controlled Substance “Takeback”

The system of registration established by the CSA prohibits a DEA registrant from acquiring controlled substances from nonregistered entities and, in turn, bars an end-user from distributing pharmaceutical controlled substances to a DEA registrant. In other words, physicians cannot receive controlled substances from anyone who does not also have a registration. Thus, physicians may not “take back” prescribed medications from patients or their family members. Similarly, except in cases of a drug being recalled or a dispensing error, patients are not allowed to return controlled medications to a pharmacy.

Information on how a patient or family member should properly dispose of medication is commonly misunderstood. DEA regulations provide a process for nonregistrants to dispose of unused medication; however, it is cumbersome and meant to be used only when dealing with large quantities of controlled substances (e.g., large quantities of abandoned drugs). In such cases, the DEA special agent in charge (SAC) may instruct on disposal, which may include transfer of the substance to a DEA registrant, delivery to a DEA agent or office, destruction in the presence of an agent of the administration or other authorized person, or by other means. The person must submit a letter to the local SAC, which includes:

• Name and address of the person;
• Name and quantity of each controlled substance to be disposed of;
• Explanation of how the applicant obtained the controlled substance, if known; and
• Name, address, and registration number, if known, of the person who possessed the controlled substances prior to the applicant.

Federal legislation also provides a way for the DEA to grant approval to law-enforcement agencies to operate “takeback” programs. The regulation states that “any person in possession of a controlled substance and desiring to dispose of such substance may request assistance from the SAC in the area in which the person is located.” The regulation allows the SAC to authorize and specify the means of disposal to assure that the controlled substances do not become available to unauthorized persons.

State and local government agencies and community associations might hold takeback programs only if law enforcement makes the request, takes custody of the controlled substances, and is responsible for the disposal.

The U.S. Office of National Drug Control Policy has published guidelines for medication disposal. These guidelines advise flushing medications only if the prescription label or accompanying patient information specifically states to do so. Instead of flushing, the guidelines recommend that medications be disposed of through a takeback program or by:

• Taking the prescription drugs out of their original containers;
• Mixing the drugs with an undesirable substance, such as cat litter or used coffee grounds;
• Placing the mixture into a disposable container with a lid, such as an empty margarine tub, or into a sealable bag;
• Concealing or removing personal information, including Rx number, on the empty containers by covering it with black permanent marker or duct tape, or by scratching it off; and
• Placing the sealed container with the mixture, and the empty drug containers, in the trash.

Unused Medication Donation

The rising cost of prescription medication leaves many questioning whether there is a need for a safe method to allow unused medication to be donated to others. At least 10 states have passed laws allowing or encouraging the donation of unused pharmaceutical drugs. Many of these programs involve healthcare facilities, nursing homes, or pharmacies. The CSA and current DEA regulations, however, prohibit patients from delivering or distributing controlled substances to a DEA registrant, even if it is for the purpose of a donation. Moreover, the Food and Drug Administration (FDA) does not permit redistribution of medications, except under limited circumstances.

Consequently, state law may be inconsistent with federal law for donation and reuse of controlled substances.

Conclusion

Physicians who fail to comply with CSA handling requirements are subject to criminal charges, discipline against their DEA registration, and discipline against their license to practice medicine. Consequently, physicians should use caution whenever handling unused medication.

The application of various aspects of the CSA and implementing rules is situation-specific. Moreover, the DEA may issue additional regulations. Accordingly, if you have a question about a specific situation, consult an attorney, or contact your local DEA field division office and ask for the diversion duty agent. TH

Patrick O’Rourke works in the Office of University Counsel, Department of Litigation, University of Colorado Denver.

Recent media reports about the dangers surrounding unused prescription medications, including abuse by teens and medications finding their way into the water supply, have prompted an increase in inquiries to healthcare providers about disposing of unused medication. These issues are complicated when controlled substances are involved.

Often, providers are unsure how to respond to patient questions about medication disposal. For example, what would you do if a patient requests an alternative medication because of an unwanted side effect and brings the originally prescribed medication back to you? What if the family of a recently expired patient brings unused medication to you and asks you to donate it to other patients? What if you have a colleague who performs mission work; could you accept and donate unused medication for use in another country?

Unfortunately, the Controlled Substances Act (CSA) does not provide a readily available mechanism to accomplish efficient, secure, and environmentally sound methods to collect and use or dispose of unwanted controlled substances. This article explains the rules physicians must adhere to and guidelines for “taking back” controlled substances.

The Legislation

Enacted in 1970, the CSA combined all existing federal drug laws into a single statute. It created five “schedules” in which certain drugs are classified. These “scheduled” drugs are commonly referred to as controlled substances. A drug’s classification depends on its potential for abuse and its currently accepted medical use in the U.S. Additionally, provisions of international treaties impact classification.

Under the classification system, Schedule I drugs have a high potential for abuse and have no currently accepted medical use in treatment in the U.S. In contrast, Schedule V drugs have a low potential for abuse and do have a currently accepted medical use in treatment in the U.S.

The CSA governs the manufacture, import, export, possession, use, and distribution of controlled substances. In doing so, the CSA established a system to register those authorized to handle controlled substances. Manufacturers, dispensers, distributors, and individual practitioners who prescribe controlled substances must be registered with the Drug Enforcement Administration (DEA).

The CSA requires registrants to keep certain records for at least two years related to their handling of controlled substances. For example, physician registrants must keep records of controlled substances in Schedules II, III, IV, and V that are dispensed via methods other than prescribing or administering (e.g., industry samples). Inventories of controlled substances are required. Most notably, physicians generally are not required to keep records of prescribed medications; however, records must be kept if drugs are dispensed or administered. Moreover, there are heightened recordkeeping responsibilities for providers who prescribe, dispense, or administer for maintenance or detoxification.

Controlled Substance “Takeback”

The system of registration established by the CSA prohibits a DEA registrant from acquiring controlled substances from nonregistered entities and, in turn, bars an end-user from distributing pharmaceutical controlled substances to a DEA registrant. In other words, physicians cannot receive controlled substances from anyone who does not also have a registration. Thus, physicians may not “take back” prescribed medications from patients or their family members. Similarly, except in cases of a drug being recalled or a dispensing error, patients are not allowed to return controlled medications to a pharmacy.

Information on how a patient or family member should properly dispose of medication is commonly misunderstood. DEA regulations provide a process for nonregistrants to dispose of unused medication; however, it is cumbersome and meant to be used only when dealing with large quantities of controlled substances (e.g., large quantities of abandoned drugs). In such cases, the DEA special agent in charge (SAC) may instruct on disposal, which may include transfer of the substance to a DEA registrant, delivery to a DEA agent or office, destruction in the presence of an agent of the administration or other authorized person, or by other means. The person must submit a letter to the local SAC, which includes:

• Name and address of the person;
• Name and quantity of each controlled substance to be disposed of;
• Explanation of how the applicant obtained the controlled substance, if known; and
• Name, address, and registration number, if known, of the person who possessed the controlled substances prior to the applicant.

Federal legislation also provides a way for the DEA to grant approval to law-enforcement agencies to operate “takeback” programs. The regulation states that “any person in possession of a controlled substance and desiring to dispose of such substance may request assistance from the SAC in the area in which the person is located.” The regulation allows the SAC to authorize and specify the means of disposal to assure that the controlled substances do not become available to unauthorized persons.

State and local government agencies and community associations might hold takeback programs only if law enforcement makes the request, takes custody of the controlled substances, and is responsible for the disposal.

The U.S. Office of National Drug Control Policy has published guidelines for medication disposal. These guidelines advise flushing medications only if the prescription label or accompanying patient information specifically states to do so. Instead of flushing, the guidelines recommend that medications be disposed of through a takeback program or by:

• Taking the prescription drugs out of their original containers;
• Mixing the drugs with an undesirable substance, such as cat litter or used coffee grounds;
• Placing the mixture into a disposable container with a lid, such as an empty margarine tub, or into a sealable bag;
• Concealing or removing personal information, including Rx number, on the empty containers by covering it with black permanent marker or duct tape, or by scratching it off; and
• Placing the sealed container with the mixture, and the empty drug containers, in the trash.

Unused Medication Donation

The rising cost of prescription medication leaves many questioning whether there is a need for a safe method to allow unused medication to be donated to others. At least 10 states have passed laws allowing or encouraging the donation of unused pharmaceutical drugs. Many of these programs involve healthcare facilities, nursing homes, or pharmacies. The CSA and current DEA regulations, however, prohibit patients from delivering or distributing controlled substances to a DEA registrant, even if it is for the purpose of a donation. Moreover, the Food and Drug Administration (FDA) does not permit redistribution of medications, except under limited circumstances.

Consequently, state law may be inconsistent with federal law for donation and reuse of controlled substances.

Conclusion

Physicians who fail to comply with CSA handling requirements are subject to criminal charges, discipline against their DEA registration, and discipline against their license to practice medicine. Consequently, physicians should use caution whenever handling unused medication.

The application of various aspects of the CSA and implementing rules is situation-specific. Moreover, the DEA may issue additional regulations. Accordingly, if you have a question about a specific situation, consult an attorney, or contact your local DEA field division office and ask for the diversion duty agent. TH

Patrick O’Rourke works in the Office of University Counsel, Department of Litigation, University of Colorado Denver.

Dear Dr. Mossman:
One of my patients, Ms. A, keeps calling in to refill her prescription, but will not come in for an appointment; she needs the medication, but I really shouldn’t keep prescribing it without seeing her. Another patient, Mr. B, has an open chart, but he stopped seeing me last year after I treated him for an acute depressive episode. May I “fire” these patients? If so, what should I do?—Submitted by “Dr. C”

All physicians occasionally encounter patients whom we’d like to stop treating, but because we feel devoted to those we treat, the idea of “firing” a patient makes us uncomfortable. Sometimes, however, ending a treatment relationship is the right choice for the doctor and patient.¹

To know why, how, and when you may terminate your professional relationship with a patient, you need to:

• understand the legal and ethical status of a doctor-patient relationship
• know the proper way to end treatment relationships
• decide whether ending your care of the patient is the right medical and ethical choice.

After exploring these points, we’ll return to the cases of Ms. A and Mr. B and consider what Dr. C might do.

Doctor-patient relationships

Legal and medical authorities characterize the treatment relationship as an implicit contract that imposes certain obligations on the doctor and the patient.^2,3 Doctors are compelled to conduct themselves in accordance with the prevailing “standard of care.” Patients’ obligations include being honest and cooperating with care once they have agreed to a treatment plan (Table 1).³

Patients may stop seeing their doctors at any time, but a physician usually must continue to provide all necessary medical attention until either the treatment episode has concluded or both parties agree to end the doctor-patient relationship.² If a physician wishes to withdraw from a case before the need for services has ended, the physician must either make arrangements for another competent physician to assume care or give the patient ample notice and opportunity to obtain treatment elsewhere.² If a doctor fails to do this and harm to the patient results, the doctor is guilty of “abandonment,” legally defined as termination of the physician-patient relationship “at an unreasonable time or without affording the patient the opportunity to procure an equally qualified replacement.”² Physician abandonment can lead to malpractice liability,⁴ complaints to state licensing authorities,⁵ and ethical condemnation.⁶

Table 1

A patient’s responsibilities

Terminating without abandoning

Doctors commonly terminate care of their patients when they decide to move or close their practices. Accusations of abandonment may arise if such career decisions are executed improperly, but these matters are not as emotionally troubling for physicians as a decision to “fire” a patient because of the patient’s behavior. Common, legitimate reasons a doctor may consider unilateral termination appear in Table 2.^7,8

Certain circumstances are not valid grounds for terminating a doctor-patient relationship. You cannot ethically decline to treat a patient whose problem lies within your areas of clinical competence solely because the patient is seropositive for human immunodeficiency virus,⁹ nor because of a patient’s race, religion, or other reasons that would constitute illegal discrimination.³ Doctors who practice in rural areas must be especially cautious about terminating care because their patients may have limited access to alternate care sources.¹⁰

Meeting with or verbally informing a patient of a termination may be reasonable in some cases, but appropriate unilateral termination of a patient usually requires providing written notification to the patient or person responsible for the patient’s care. Attorneys who specialize in risk management advise doctors to seek legal consultation when preparing a termination-of-care letter and to send it by certified mail. The letter should conform to any applicable rules or regulations where you practice. Typically, required content includes:

• notification that the physician-patient relationship is terminated
• a statement of willingness to provide emergency treatment and access to services for up to 30 days from the mailing date to allow the patient to arrange care from another provider
• an offer to transfer records to the new provider upon receiving the patient’s signed authorization to do so.¹¹

More discussion of the possible contents of termination letters appears in Table 3.^7,12-14

Table 2

Common reasons to consider terminating a patient’s care

Table 3

Potential elements of termination letters

Deciding to ‘fire‘ a patient

Physicians in all specialties encounter patients whose actions generate intensely negative feelings—resentment, anger, even hate.¹⁵ But “firing” a patient should be a rare circumstance that’s not undertaken lightly. Many different circumstances can make it reasonable for a physician to consider terminating a patient’s care, so it’s difficult to provide general advice about when firing a patient really is the right thing to do. But 1 “prescription” seems clear: consult a respected colleague first. According to psychiatrist Robert Michels, “Any physician who is thinking of firing a patient should first speak to a colleague… This is an enormous decision and, while it might even be right at times, the physician is probably having a countertransference reaction to his patient and should really understand that before taking action.”¹

Having an anonymous consultation with a colleague offers several potential benefits, such as:

• If you’re thinking about firing a patient, you’re probably very upset. A colleague who isn’t emotionally involved can help you assess the matter more dispassionately.
• You may be feeling guilty about disliking the patient. A colleague’s empathy (“Of course you’re angry!”) can help you avoid disowning your feelings, which may make it easier to figure out how to use those feelings to help the patient.^15,16
• A colleague may think of solutions that you haven’t considered, which might help you feel less frustrated about how treatment is going.
• A colleague may help you see ways that you’re actually helping the patient, despite feeling that your work is futile.
• If a thoughtful colleague confirms your view that terminating care is appropriate, you’ll feel better about the decision. If you document the anonymous consultation in the patient’s chart, you’ll create a record of your reasonableness and prudence—which will be helpful if you have to defend your action in court.¹²

Revisiting the case patients

With these thoughts in mind, we return to Dr. C’s clinical dilemmas.

Ms. A. In retrospect, Dr. C might wish he had been clearer with Ms. A about how often she would need to see him for medication monitoring. At this point, however, Dr. C still has options besides firing Ms. A:

• Dr. C can call Ms. A to ask how she’s doing and to explain his medical responsibility to see and reassess her if he is to continue prescribing her medication. He can then follow up with a letter summarizing the conversation.
• Dr. C might ask whether some problem is preventing Ms. A from making an appointment. If, for example, Ms. A has lost her job and health insurance coverage for office visits, Dr. C might suggest options (such as seeing Ms. A once at no charge) or help Ms. A find other ways to obtain follow-up care.

Mr. B. Concerning Mr. B, we wonder, “Why not just leave the chart open?” As is the case with care provided by other specialists—including internists, obstetricians, or dermatologists—psychiatric treatment may occur in discrete episodes over many years. Patients regard a previous care provider as “their doctor” for decades after a treatment episode, and it’s comforting and valuable for former patients to know they can see their “shrink” again if they need to.

Related Resource

• Henderson SM. Advice on abandonment. Oklahoma Board of Medical Licensure and Supervision. www.okmedicalboard.org/download/19980401MD.htm.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dear Dr. Mossman:
One of my patients, Ms. A, keeps calling in to refill her prescription, but will not come in for an appointment; she needs the medication, but I really shouldn’t keep prescribing it without seeing her. Another patient, Mr. B, has an open chart, but he stopped seeing me last year after I treated him for an acute depressive episode. May I “fire” these patients? If so, what should I do?—Submitted by “Dr. C”

All physicians occasionally encounter patients whom we’d like to stop treating, but because we feel devoted to those we treat, the idea of “firing” a patient makes us uncomfortable. Sometimes, however, ending a treatment relationship is the right choice for the doctor and patient.¹

To know why, how, and when you may terminate your professional relationship with a patient, you need to:

• understand the legal and ethical status of a doctor-patient relationship
• know the proper way to end treatment relationships
• decide whether ending your care of the patient is the right medical and ethical choice.

After exploring these points, we’ll return to the cases of Ms. A and Mr. B and consider what Dr. C might do.

Doctor-patient relationships

Legal and medical authorities characterize the treatment relationship as an implicit contract that imposes certain obligations on the doctor and the patient.^2,3 Doctors are compelled to conduct themselves in accordance with the prevailing “standard of care.” Patients’ obligations include being honest and cooperating with care once they have agreed to a treatment plan (Table 1).³

Patients may stop seeing their doctors at any time, but a physician usually must continue to provide all necessary medical attention until either the treatment episode has concluded or both parties agree to end the doctor-patient relationship.² If a physician wishes to withdraw from a case before the need for services has ended, the physician must either make arrangements for another competent physician to assume care or give the patient ample notice and opportunity to obtain treatment elsewhere.² If a doctor fails to do this and harm to the patient results, the doctor is guilty of “abandonment,” legally defined as termination of the physician-patient relationship “at an unreasonable time or without affording the patient the opportunity to procure an equally qualified replacement.”² Physician abandonment can lead to malpractice liability,⁴ complaints to state licensing authorities,⁵ and ethical condemnation.⁶

Table 1

A patient’s responsibilities

Terminating without abandoning

Doctors commonly terminate care of their patients when they decide to move or close their practices. Accusations of abandonment may arise if such career decisions are executed improperly, but these matters are not as emotionally troubling for physicians as a decision to “fire” a patient because of the patient’s behavior. Common, legitimate reasons a doctor may consider unilateral termination appear in Table 2.^7,8

Certain circumstances are not valid grounds for terminating a doctor-patient relationship. You cannot ethically decline to treat a patient whose problem lies within your areas of clinical competence solely because the patient is seropositive for human immunodeficiency virus,⁹ nor because of a patient’s race, religion, or other reasons that would constitute illegal discrimination.³ Doctors who practice in rural areas must be especially cautious about terminating care because their patients may have limited access to alternate care sources.¹⁰

Meeting with or verbally informing a patient of a termination may be reasonable in some cases, but appropriate unilateral termination of a patient usually requires providing written notification to the patient or person responsible for the patient’s care. Attorneys who specialize in risk management advise doctors to seek legal consultation when preparing a termination-of-care letter and to send it by certified mail. The letter should conform to any applicable rules or regulations where you practice. Typically, required content includes:

• notification that the physician-patient relationship is terminated
• a statement of willingness to provide emergency treatment and access to services for up to 30 days from the mailing date to allow the patient to arrange care from another provider
• an offer to transfer records to the new provider upon receiving the patient’s signed authorization to do so.¹¹

More discussion of the possible contents of termination letters appears in Table 3.^7,12-14

Table 2

Common reasons to consider terminating a patient’s care

Table 3

Potential elements of termination letters

Deciding to ‘fire‘ a patient

Physicians in all specialties encounter patients whose actions generate intensely negative feelings—resentment, anger, even hate.¹⁵ But “firing” a patient should be a rare circumstance that’s not undertaken lightly. Many different circumstances can make it reasonable for a physician to consider terminating a patient’s care, so it’s difficult to provide general advice about when firing a patient really is the right thing to do. But 1 “prescription” seems clear: consult a respected colleague first. According to psychiatrist Robert Michels, “Any physician who is thinking of firing a patient should first speak to a colleague… This is an enormous decision and, while it might even be right at times, the physician is probably having a countertransference reaction to his patient and should really understand that before taking action.”¹

Having an anonymous consultation with a colleague offers several potential benefits, such as:

• If you’re thinking about firing a patient, you’re probably very upset. A colleague who isn’t emotionally involved can help you assess the matter more dispassionately.
• You may be feeling guilty about disliking the patient. A colleague’s empathy (“Of course you’re angry!”) can help you avoid disowning your feelings, which may make it easier to figure out how to use those feelings to help the patient.^15,16
• A colleague may think of solutions that you haven’t considered, which might help you feel less frustrated about how treatment is going.
• A colleague may help you see ways that you’re actually helping the patient, despite feeling that your work is futile.
• If a thoughtful colleague confirms your view that terminating care is appropriate, you’ll feel better about the decision. If you document the anonymous consultation in the patient’s chart, you’ll create a record of your reasonableness and prudence—which will be helpful if you have to defend your action in court.¹²

Revisiting the case patients

With these thoughts in mind, we return to Dr. C’s clinical dilemmas.

Ms. A. In retrospect, Dr. C might wish he had been clearer with Ms. A about how often she would need to see him for medication monitoring. At this point, however, Dr. C still has options besides firing Ms. A:

• Dr. C can call Ms. A to ask how she’s doing and to explain his medical responsibility to see and reassess her if he is to continue prescribing her medication. He can then follow up with a letter summarizing the conversation.
• Dr. C might ask whether some problem is preventing Ms. A from making an appointment. If, for example, Ms. A has lost her job and health insurance coverage for office visits, Dr. C might suggest options (such as seeing Ms. A once at no charge) or help Ms. A find other ways to obtain follow-up care.

Mr. B. Concerning Mr. B, we wonder, “Why not just leave the chart open?” As is the case with care provided by other specialists—including internists, obstetricians, or dermatologists—psychiatric treatment may occur in discrete episodes over many years. Patients regard a previous care provider as “their doctor” for decades after a treatment episode, and it’s comforting and valuable for former patients to know they can see their “shrink” again if they need to.

Related Resource

• Henderson SM. Advice on abandonment. Oklahoma Board of Medical Licensure and Supervision. www.okmedicalboard.org/download/19980401MD.htm.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dear Dr. Mossman:
One of my patients, Ms. A, keeps calling in to refill her prescription, but will not come in for an appointment; she needs the medication, but I really shouldn’t keep prescribing it without seeing her. Another patient, Mr. B, has an open chart, but he stopped seeing me last year after I treated him for an acute depressive episode. May I “fire” these patients? If so, what should I do?—Submitted by “Dr. C”

All physicians occasionally encounter patients whom we’d like to stop treating, but because we feel devoted to those we treat, the idea of “firing” a patient makes us uncomfortable. Sometimes, however, ending a treatment relationship is the right choice for the doctor and patient.¹

To know why, how, and when you may terminate your professional relationship with a patient, you need to:

• understand the legal and ethical status of a doctor-patient relationship
• know the proper way to end treatment relationships
• decide whether ending your care of the patient is the right medical and ethical choice.

After exploring these points, we’ll return to the cases of Ms. A and Mr. B and consider what Dr. C might do.

Doctor-patient relationships

Legal and medical authorities characterize the treatment relationship as an implicit contract that imposes certain obligations on the doctor and the patient.^2,3 Doctors are compelled to conduct themselves in accordance with the prevailing “standard of care.” Patients’ obligations include being honest and cooperating with care once they have agreed to a treatment plan (Table 1).³

Patients may stop seeing their doctors at any time, but a physician usually must continue to provide all necessary medical attention until either the treatment episode has concluded or both parties agree to end the doctor-patient relationship.² If a physician wishes to withdraw from a case before the need for services has ended, the physician must either make arrangements for another competent physician to assume care or give the patient ample notice and opportunity to obtain treatment elsewhere.² If a doctor fails to do this and harm to the patient results, the doctor is guilty of “abandonment,” legally defined as termination of the physician-patient relationship “at an unreasonable time or without affording the patient the opportunity to procure an equally qualified replacement.”² Physician abandonment can lead to malpractice liability,⁴ complaints to state licensing authorities,⁵ and ethical condemnation.⁶

Table 1

A patient’s responsibilities

Terminating without abandoning

Doctors commonly terminate care of their patients when they decide to move or close their practices. Accusations of abandonment may arise if such career decisions are executed improperly, but these matters are not as emotionally troubling for physicians as a decision to “fire” a patient because of the patient’s behavior. Common, legitimate reasons a doctor may consider unilateral termination appear in Table 2.^7,8

Certain circumstances are not valid grounds for terminating a doctor-patient relationship. You cannot ethically decline to treat a patient whose problem lies within your areas of clinical competence solely because the patient is seropositive for human immunodeficiency virus,⁹ nor because of a patient’s race, religion, or other reasons that would constitute illegal discrimination.³ Doctors who practice in rural areas must be especially cautious about terminating care because their patients may have limited access to alternate care sources.¹⁰

Meeting with or verbally informing a patient of a termination may be reasonable in some cases, but appropriate unilateral termination of a patient usually requires providing written notification to the patient or person responsible for the patient’s care. Attorneys who specialize in risk management advise doctors to seek legal consultation when preparing a termination-of-care letter and to send it by certified mail. The letter should conform to any applicable rules or regulations where you practice. Typically, required content includes:

• notification that the physician-patient relationship is terminated
• a statement of willingness to provide emergency treatment and access to services for up to 30 days from the mailing date to allow the patient to arrange care from another provider
• an offer to transfer records to the new provider upon receiving the patient’s signed authorization to do so.¹¹

More discussion of the possible contents of termination letters appears in Table 3.^7,12-14

Table 2

Common reasons to consider terminating a patient’s care

Table 3

Potential elements of termination letters

Deciding to ‘fire‘ a patient

Physicians in all specialties encounter patients whose actions generate intensely negative feelings—resentment, anger, even hate.¹⁵ But “firing” a patient should be a rare circumstance that’s not undertaken lightly. Many different circumstances can make it reasonable for a physician to consider terminating a patient’s care, so it’s difficult to provide general advice about when firing a patient really is the right thing to do. But 1 “prescription” seems clear: consult a respected colleague first. According to psychiatrist Robert Michels, “Any physician who is thinking of firing a patient should first speak to a colleague… This is an enormous decision and, while it might even be right at times, the physician is probably having a countertransference reaction to his patient and should really understand that before taking action.”¹

Having an anonymous consultation with a colleague offers several potential benefits, such as:

• If you’re thinking about firing a patient, you’re probably very upset. A colleague who isn’t emotionally involved can help you assess the matter more dispassionately.
• You may be feeling guilty about disliking the patient. A colleague’s empathy (“Of course you’re angry!”) can help you avoid disowning your feelings, which may make it easier to figure out how to use those feelings to help the patient.^15,16
• A colleague may think of solutions that you haven’t considered, which might help you feel less frustrated about how treatment is going.
• A colleague may help you see ways that you’re actually helping the patient, despite feeling that your work is futile.
• If a thoughtful colleague confirms your view that terminating care is appropriate, you’ll feel better about the decision. If you document the anonymous consultation in the patient’s chart, you’ll create a record of your reasonableness and prudence—which will be helpful if you have to defend your action in court.¹²

Revisiting the case patients

With these thoughts in mind, we return to Dr. C’s clinical dilemmas.

Ms. A. In retrospect, Dr. C might wish he had been clearer with Ms. A about how often she would need to see him for medication monitoring. At this point, however, Dr. C still has options besides firing Ms. A:

• Dr. C can call Ms. A to ask how she’s doing and to explain his medical responsibility to see and reassess her if he is to continue prescribing her medication. He can then follow up with a letter summarizing the conversation.
• Dr. C might ask whether some problem is preventing Ms. A from making an appointment. If, for example, Ms. A has lost her job and health insurance coverage for office visits, Dr. C might suggest options (such as seeing Ms. A once at no charge) or help Ms. A find other ways to obtain follow-up care.

Mr. B. Concerning Mr. B, we wonder, “Why not just leave the chart open?” As is the case with care provided by other specialists—including internists, obstetricians, or dermatologists—psychiatric treatment may occur in discrete episodes over many years. Patients regard a previous care provider as “their doctor” for decades after a treatment episode, and it’s comforting and valuable for former patients to know they can see their “shrink” again if they need to.

Related Resource

• Henderson SM. Advice on abandonment. Oklahoma Board of Medical Licensure and Supervision. www.okmedicalboard.org/download/19980401MD.htm.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Bryn Nelson in the October issue of The Hospitalist (see “A Taxing Future for HM?,” p. 16) incorrectly states that Blue Cross Blue Shield of North Carolina’s refund to customers was a result of an overcharge. In point of fact, the refund is a result of a one-time opportunity due to the changes brought about by the health reform law. The new rating and grandfathering rules in the Patient Protection and Affordable Care Act create a one-time circumstance enabling these refunds.

The funds come from active life reserves, which are portions of the premium set aside in the early years of a policy to pay future claims and keep rates stable as customers’ medical expenses rise during the life of the policy. However, policies purchased or substantially modified after March 23, 2010, will end in 2014 under the new healthcare reform law, which is when the new products under health reform will be introduced. Therefore, the reserves held for these products will cover a much shorter period of time, allowing for these funds to be released.

Lew Borman,

media relations,

Blue Cross Blue Shield of North Carolina

Bryn Nelson in the October issue of The Hospitalist (see “A Taxing Future for HM?,” p. 16) incorrectly states that Blue Cross Blue Shield of North Carolina’s refund to customers was a result of an overcharge. In point of fact, the refund is a result of a one-time opportunity due to the changes brought about by the health reform law. The new rating and grandfathering rules in the Patient Protection and Affordable Care Act create a one-time circumstance enabling these refunds.

The funds come from active life reserves, which are portions of the premium set aside in the early years of a policy to pay future claims and keep rates stable as customers’ medical expenses rise during the life of the policy. However, policies purchased or substantially modified after March 23, 2010, will end in 2014 under the new healthcare reform law, which is when the new products under health reform will be introduced. Therefore, the reserves held for these products will cover a much shorter period of time, allowing for these funds to be released.

Lew Borman,

media relations,

Blue Cross Blue Shield of North Carolina

Bryn Nelson in the October issue of The Hospitalist (see “A Taxing Future for HM?,” p. 16) incorrectly states that Blue Cross Blue Shield of North Carolina’s refund to customers was a result of an overcharge. In point of fact, the refund is a result of a one-time opportunity due to the changes brought about by the health reform law. The new rating and grandfathering rules in the Patient Protection and Affordable Care Act create a one-time circumstance enabling these refunds.

The funds come from active life reserves, which are portions of the premium set aside in the early years of a policy to pay future claims and keep rates stable as customers’ medical expenses rise during the life of the policy. However, policies purchased or substantially modified after March 23, 2010, will end in 2014 under the new healthcare reform law, which is when the new products under health reform will be introduced. Therefore, the reserves held for these products will cover a much shorter period of time, allowing for these funds to be released.

Lew Borman,

media relations,

Blue Cross Blue Shield of North Carolina

When Congress returns for a likely lame-duck session after the midterm elections, the biggest battle might be fought over whether to extend the 2001 and 2003 tax cuts to everyone or only to those earning less than $200,000 annually ($250,000 for families). And depending on the makeup of the 112th Congress, which will be seated in January, Republicans might try to make good on a campaign pledge to repeal all or most of the healthcare reform legislation.

The expected flashpoints are being teased endlessly with media sound bites featuring phrases that most of us love to hate: higher taxes, spiraling medical bills, soaring insurance premiums. Insurance companies already are blaming a spike in premiums on the healthcare legislation, claiming that new provisions and mandates are forcing them to further hike their rates.

Closer to home, the high-profile frays could put hospitalists in the awkward position of supporting political positions that sock them in the wallet. After all, doctors are workers and healthcare consumers, too. So what impact could higher taxes and higher insurance premiums really have? Let’s start with health insurance.

Insurance Cost Increases

Signed into law in March, the Affordable Care Act includes tax credits for small businesses to help defray the costs of health insurance coverage. But in 2013, it also raises the threshold for medical expense deductions for most taxpayers, to 10% from 7.5% of adjusted gross income. In other words, families can claim tax deductions only after having spent 10% or more of their adjusted gross income on medical bills. For families with hefty medical bills, that 2.5% difference could translate into a significant shortfall.

CMS was able to negotiate with insurers to achieve a slight drop in Medicare Advantage premiums, but many individual states have had less luck in preventing rate increases from private insurers who blame their higher premiums on new mandates. The Wall Street Journal has documented rate increases of 18% in states like Wisconsin and North Carolina—about 9% of which insurance company officials pinned on the new law.¹ Such increases are hardly inevitable, however. The Obama administration’s White House blog, for instance, has cited the example of North Carolina Blue Cross and Blue Shield, which announced Sept. 20 that it will provide $156 million in refunds to more than 215,000 customers after state regulators found an overcharge that should be reversed due to new rules in the reform law.² WellPoint will similarly refund $20 million to its health insurance customers in Colorado.²

The requested premium increases and identified overcharges have contributed to plenty of finger-pointing among insurers, state regulators, and the Obama administration, which has assailed insurers for using the law as a convenient excuse to raise rates. Highlighting the unease of many consumers, however, is the verdict that the proposed increases—if approved—would hit small businesses and individuals hardest.

According to the State of Hospital Medicine: 2010 Report Based on 2009 Data, released in September by SHM and the Medical Group Management Association, participating hospitalist groups have a median of 10 physician full-time equivalents. Roughly 25% of respondents are in physician-owned groups, while 14% are in a management services organization (MSO) or physician practice management company (PPMC). Smaller HM groups wouldn’t be alone in feeling the pinch, but they might need to consider some serious comparison-shopping to avoid costly premium increases.

Cherilyn Murer, president and CEO of Joliet, Ill.-based Murer Consultants Inc., has worked with healthcare systems and providers in 42 states, but even her company has not been immune to having to contend with rising premiums. “Our managing partner just renegotiated our health benefits [premiums] that were supposed to have gone up 30% by our previous carrier,” Murer says. “Through protracted negotiations and diligence, he was able to find a plan that did not increase our costs, and retained pretty much the same benefits.”

For at least the next three to five years, Murer says, niche firms will need to be diligent about shopping around and managing their expenses in a volatile insurance marketplace. Healthcare reform, she says, is certainly not a panacea for reining in costs, but “just the beginning.”

Concerns over healthcare costs, in fact, could be among the factors driving what Robert Zipper, MD, FHM, regional chief medical officer for Tacoma, Wash.-based Sound Physicians, sees as continuing consolidation among hospitalist groups. “By that, I mean that either groups are swallowed up by the hospital in which they work or they become part of a regional or national company,” he says. Sound Physicians, with about 400 hospitalists in seven states, offers health insurance policies that don’t vary by state, easing its negotiations.

Eyes on the Bottom Line

What about the dreaded “T” word? Dr. Zipper says he hasn’t heard that many concerns about the potential tax increase just yet. “I think it’s not an issue to hospitalists in a broad sense yet,” he says, “but if you look at the salary trajectory and where things have been over the past 10 years, it’s pretty easy to predict that it will be an issue for single-income [households] where the hospitalist is the sole breadwinner.”

The 2010 State of Hospital Medicine report, which surveyed 4,211 nonacademic hospitalists from 443 groups, found a median annual income of $215,000. Calculating trends from past income surveys is difficult due to very different respondent populations, but many hospitalists are clearly near or above the $200,000 threshold for individuals and near the $250,000 threshold for families already, even before considering spousal income. The survey, for example, found median salaries of about $235,700 in the 13 states that make up the Southern region.

Even if higher-earning hospitalists are subjected to a higher tax rate next year—if the current rates expire, a climb of 4.6 percentage points, to 39.6% from 35%—not all of them are necessarily opposed to it. Political polling on the issue isn’t broken down by specific professions, but a number of blogs have pointed to a Quinnipiac University poll conducted back in March that suggested nearly two-thirds of upper-income Americans were prepared to sacrifice some of their take-home pay to help reduce the deficit. In that poll (www.quinnipiac.edu/x1295.xml?ReleaseID=1438), some 64% of respondents earning more than $250,000 agreed that raising income taxes on themselves and other households making more than $250,000 should be a main part of any government approach to the deficit.

If taxes and insurance premiums are more immediate concerns, some HM observers are eyeing longer trends that could impact the pre-tax pay of the profession. Most hospitalists still earn far less than their specialist counterparts, of course, but increasing demand for hospitalist services has helped fuel a rise in median salaries. Last year, some observers predicted that after an impressive run, annual pay would plateau or even fall, given the current economic uncertainty, tightening profit margins, and assessment that many hospitals run HM programs at a loss.³ And in the current RVU-driven system, the “What have you done for me lately?” mentality can indeed make it difficult for hospitalists to demonstrate a solid return on the investment.

The State of Hospital Medicine report suggests that respondent HM groups have been subsidized by an average of $111,486 per physician FTE (median is $98,253), with the highest numbers in hospital-owned practices. But many experts see a window of a few years in which new healthcare delivery and payment experiments will be trotted out, whether modeled on a bundled system, accountable-care organization (ACO), or other vehicle. Under these models, payment incentives to physicians—and to hospitalists especially—could be fundamentally restructured to better reflect their true contributions as the emphasis on quality and efficiency increases.

Within the next three years, Murer says, hospitalists need to continue to infiltrate inpatient medical services, demonstrate their worth, and show the cost efficiencies that arise from their profession. “I think they’ve got a window of three years to really decide how much of that [inpatient physician] market they will retain,” she says.

Despite the current volatility, both Murer and Dr. Zipper agree that hospitalists are well positioned to take advantage of the coming changes in the healthcare delivery system. But to seize the opportunity, hospitalists must clearly demonstrate the necessity of their services in the emerging models of care and claim an early seat at the table where decisions will be made about how the pot of money is dispersed. Doing so could help resolve one of the most important financial considerations of all: job security. TH

Bryn Nelson is a freelance medical writer based in Seattle.

References

1. Adamy J. Health insurers plan hikes. Wall Street Journal website. Available at: http://online.wsj.com/article/SB10001424052748703720004575478200948908976.html. Accessed Sept. 21, 2010.
2. Cutter S. Look you in the eye. The White House website. Available at: www.whitehouse.gov/blog/2010/09/23/look-you-eye. Accessed Sept. 27, 2010.
3. How will the economy affect hospitalist salaries? MedPage Today website. Available at: www.kevinmd .com/blog/2009/03/how-will-economy-affect-hospitalist-2.html. Accessed Sept. 27, 2010.

When Congress returns for a likely lame-duck session after the midterm elections, the biggest battle might be fought over whether to extend the 2001 and 2003 tax cuts to everyone or only to those earning less than $200,000 annually ($250,000 for families). And depending on the makeup of the 112th Congress, which will be seated in January, Republicans might try to make good on a campaign pledge to repeal all or most of the healthcare reform legislation.

The expected flashpoints are being teased endlessly with media sound bites featuring phrases that most of us love to hate: higher taxes, spiraling medical bills, soaring insurance premiums. Insurance companies already are blaming a spike in premiums on the healthcare legislation, claiming that new provisions and mandates are forcing them to further hike their rates.

Closer to home, the high-profile frays could put hospitalists in the awkward position of supporting political positions that sock them in the wallet. After all, doctors are workers and healthcare consumers, too. So what impact could higher taxes and higher insurance premiums really have? Let’s start with health insurance.

Insurance Cost Increases

Signed into law in March, the Affordable Care Act includes tax credits for small businesses to help defray the costs of health insurance coverage. But in 2013, it also raises the threshold for medical expense deductions for most taxpayers, to 10% from 7.5% of adjusted gross income. In other words, families can claim tax deductions only after having spent 10% or more of their adjusted gross income on medical bills. For families with hefty medical bills, that 2.5% difference could translate into a significant shortfall.

CMS was able to negotiate with insurers to achieve a slight drop in Medicare Advantage premiums, but many individual states have had less luck in preventing rate increases from private insurers who blame their higher premiums on new mandates. The Wall Street Journal has documented rate increases of 18% in states like Wisconsin and North Carolina—about 9% of which insurance company officials pinned on the new law.¹ Such increases are hardly inevitable, however. The Obama administration’s White House blog, for instance, has cited the example of North Carolina Blue Cross and Blue Shield, which announced Sept. 20 that it will provide $156 million in refunds to more than 215,000 customers after state regulators found an overcharge that should be reversed due to new rules in the reform law.² WellPoint will similarly refund $20 million to its health insurance customers in Colorado.²

The requested premium increases and identified overcharges have contributed to plenty of finger-pointing among insurers, state regulators, and the Obama administration, which has assailed insurers for using the law as a convenient excuse to raise rates. Highlighting the unease of many consumers, however, is the verdict that the proposed increases—if approved—would hit small businesses and individuals hardest.

According to the State of Hospital Medicine: 2010 Report Based on 2009 Data, released in September by SHM and the Medical Group Management Association, participating hospitalist groups have a median of 10 physician full-time equivalents. Roughly 25% of respondents are in physician-owned groups, while 14% are in a management services organization (MSO) or physician practice management company (PPMC). Smaller HM groups wouldn’t be alone in feeling the pinch, but they might need to consider some serious comparison-shopping to avoid costly premium increases.

Cherilyn Murer, president and CEO of Joliet, Ill.-based Murer Consultants Inc., has worked with healthcare systems and providers in 42 states, but even her company has not been immune to having to contend with rising premiums. “Our managing partner just renegotiated our health benefits [premiums] that were supposed to have gone up 30% by our previous carrier,” Murer says. “Through protracted negotiations and diligence, he was able to find a plan that did not increase our costs, and retained pretty much the same benefits.”

For at least the next three to five years, Murer says, niche firms will need to be diligent about shopping around and managing their expenses in a volatile insurance marketplace. Healthcare reform, she says, is certainly not a panacea for reining in costs, but “just the beginning.”

Concerns over healthcare costs, in fact, could be among the factors driving what Robert Zipper, MD, FHM, regional chief medical officer for Tacoma, Wash.-based Sound Physicians, sees as continuing consolidation among hospitalist groups. “By that, I mean that either groups are swallowed up by the hospital in which they work or they become part of a regional or national company,” he says. Sound Physicians, with about 400 hospitalists in seven states, offers health insurance policies that don’t vary by state, easing its negotiations.

Eyes on the Bottom Line

What about the dreaded “T” word? Dr. Zipper says he hasn’t heard that many concerns about the potential tax increase just yet. “I think it’s not an issue to hospitalists in a broad sense yet,” he says, “but if you look at the salary trajectory and where things have been over the past 10 years, it’s pretty easy to predict that it will be an issue for single-income [households] where the hospitalist is the sole breadwinner.”

The 2010 State of Hospital Medicine report, which surveyed 4,211 nonacademic hospitalists from 443 groups, found a median annual income of $215,000. Calculating trends from past income surveys is difficult due to very different respondent populations, but many hospitalists are clearly near or above the $200,000 threshold for individuals and near the $250,000 threshold for families already, even before considering spousal income. The survey, for example, found median salaries of about $235,700 in the 13 states that make up the Southern region.

Even if higher-earning hospitalists are subjected to a higher tax rate next year—if the current rates expire, a climb of 4.6 percentage points, to 39.6% from 35%—not all of them are necessarily opposed to it. Political polling on the issue isn’t broken down by specific professions, but a number of blogs have pointed to a Quinnipiac University poll conducted back in March that suggested nearly two-thirds of upper-income Americans were prepared to sacrifice some of their take-home pay to help reduce the deficit. In that poll (www.quinnipiac.edu/x1295.xml?ReleaseID=1438), some 64% of respondents earning more than $250,000 agreed that raising income taxes on themselves and other households making more than $250,000 should be a main part of any government approach to the deficit.

If taxes and insurance premiums are more immediate concerns, some HM observers are eyeing longer trends that could impact the pre-tax pay of the profession. Most hospitalists still earn far less than their specialist counterparts, of course, but increasing demand for hospitalist services has helped fuel a rise in median salaries. Last year, some observers predicted that after an impressive run, annual pay would plateau or even fall, given the current economic uncertainty, tightening profit margins, and assessment that many hospitals run HM programs at a loss.³ And in the current RVU-driven system, the “What have you done for me lately?” mentality can indeed make it difficult for hospitalists to demonstrate a solid return on the investment.

The State of Hospital Medicine report suggests that respondent HM groups have been subsidized by an average of $111,486 per physician FTE (median is $98,253), with the highest numbers in hospital-owned practices. But many experts see a window of a few years in which new healthcare delivery and payment experiments will be trotted out, whether modeled on a bundled system, accountable-care organization (ACO), or other vehicle. Under these models, payment incentives to physicians—and to hospitalists especially—could be fundamentally restructured to better reflect their true contributions as the emphasis on quality and efficiency increases.

Within the next three years, Murer says, hospitalists need to continue to infiltrate inpatient medical services, demonstrate their worth, and show the cost efficiencies that arise from their profession. “I think they’ve got a window of three years to really decide how much of that [inpatient physician] market they will retain,” she says.

Despite the current volatility, both Murer and Dr. Zipper agree that hospitalists are well positioned to take advantage of the coming changes in the healthcare delivery system. But to seize the opportunity, hospitalists must clearly demonstrate the necessity of their services in the emerging models of care and claim an early seat at the table where decisions will be made about how the pot of money is dispersed. Doing so could help resolve one of the most important financial considerations of all: job security. TH

Bryn Nelson is a freelance medical writer based in Seattle.

References

1. Adamy J. Health insurers plan hikes. Wall Street Journal website. Available at: http://online.wsj.com/article/SB10001424052748703720004575478200948908976.html. Accessed Sept. 21, 2010.
2. Cutter S. Look you in the eye. The White House website. Available at: www.whitehouse.gov/blog/2010/09/23/look-you-eye. Accessed Sept. 27, 2010.
3. How will the economy affect hospitalist salaries? MedPage Today website. Available at: www.kevinmd .com/blog/2009/03/how-will-economy-affect-hospitalist-2.html. Accessed Sept. 27, 2010.

When Congress returns for a likely lame-duck session after the midterm elections, the biggest battle might be fought over whether to extend the 2001 and 2003 tax cuts to everyone or only to those earning less than $200,000 annually ($250,000 for families). And depending on the makeup of the 112th Congress, which will be seated in January, Republicans might try to make good on a campaign pledge to repeal all or most of the healthcare reform legislation.

The expected flashpoints are being teased endlessly with media sound bites featuring phrases that most of us love to hate: higher taxes, spiraling medical bills, soaring insurance premiums. Insurance companies already are blaming a spike in premiums on the healthcare legislation, claiming that new provisions and mandates are forcing them to further hike their rates.

Closer to home, the high-profile frays could put hospitalists in the awkward position of supporting political positions that sock them in the wallet. After all, doctors are workers and healthcare consumers, too. So what impact could higher taxes and higher insurance premiums really have? Let’s start with health insurance.

Insurance Cost Increases

Signed into law in March, the Affordable Care Act includes tax credits for small businesses to help defray the costs of health insurance coverage. But in 2013, it also raises the threshold for medical expense deductions for most taxpayers, to 10% from 7.5% of adjusted gross income. In other words, families can claim tax deductions only after having spent 10% or more of their adjusted gross income on medical bills. For families with hefty medical bills, that 2.5% difference could translate into a significant shortfall.

CMS was able to negotiate with insurers to achieve a slight drop in Medicare Advantage premiums, but many individual states have had less luck in preventing rate increases from private insurers who blame their higher premiums on new mandates. The Wall Street Journal has documented rate increases of 18% in states like Wisconsin and North Carolina—about 9% of which insurance company officials pinned on the new law.¹ Such increases are hardly inevitable, however. The Obama administration’s White House blog, for instance, has cited the example of North Carolina Blue Cross and Blue Shield, which announced Sept. 20 that it will provide $156 million in refunds to more than 215,000 customers after state regulators found an overcharge that should be reversed due to new rules in the reform law.² WellPoint will similarly refund $20 million to its health insurance customers in Colorado.²

The requested premium increases and identified overcharges have contributed to plenty of finger-pointing among insurers, state regulators, and the Obama administration, which has assailed insurers for using the law as a convenient excuse to raise rates. Highlighting the unease of many consumers, however, is the verdict that the proposed increases—if approved—would hit small businesses and individuals hardest.

According to the State of Hospital Medicine: 2010 Report Based on 2009 Data, released in September by SHM and the Medical Group Management Association, participating hospitalist groups have a median of 10 physician full-time equivalents. Roughly 25% of respondents are in physician-owned groups, while 14% are in a management services organization (MSO) or physician practice management company (PPMC). Smaller HM groups wouldn’t be alone in feeling the pinch, but they might need to consider some serious comparison-shopping to avoid costly premium increases.

Cherilyn Murer, president and CEO of Joliet, Ill.-based Murer Consultants Inc., has worked with healthcare systems and providers in 42 states, but even her company has not been immune to having to contend with rising premiums. “Our managing partner just renegotiated our health benefits [premiums] that were supposed to have gone up 30% by our previous carrier,” Murer says. “Through protracted negotiations and diligence, he was able to find a plan that did not increase our costs, and retained pretty much the same benefits.”

For at least the next three to five years, Murer says, niche firms will need to be diligent about shopping around and managing their expenses in a volatile insurance marketplace. Healthcare reform, she says, is certainly not a panacea for reining in costs, but “just the beginning.”

Concerns over healthcare costs, in fact, could be among the factors driving what Robert Zipper, MD, FHM, regional chief medical officer for Tacoma, Wash.-based Sound Physicians, sees as continuing consolidation among hospitalist groups. “By that, I mean that either groups are swallowed up by the hospital in which they work or they become part of a regional or national company,” he says. Sound Physicians, with about 400 hospitalists in seven states, offers health insurance policies that don’t vary by state, easing its negotiations.

Eyes on the Bottom Line

What about the dreaded “T” word? Dr. Zipper says he hasn’t heard that many concerns about the potential tax increase just yet. “I think it’s not an issue to hospitalists in a broad sense yet,” he says, “but if you look at the salary trajectory and where things have been over the past 10 years, it’s pretty easy to predict that it will be an issue for single-income [households] where the hospitalist is the sole breadwinner.”

The 2010 State of Hospital Medicine report, which surveyed 4,211 nonacademic hospitalists from 443 groups, found a median annual income of $215,000. Calculating trends from past income surveys is difficult due to very different respondent populations, but many hospitalists are clearly near or above the $200,000 threshold for individuals and near the $250,000 threshold for families already, even before considering spousal income. The survey, for example, found median salaries of about $235,700 in the 13 states that make up the Southern region.

Even if higher-earning hospitalists are subjected to a higher tax rate next year—if the current rates expire, a climb of 4.6 percentage points, to 39.6% from 35%—not all of them are necessarily opposed to it. Political polling on the issue isn’t broken down by specific professions, but a number of blogs have pointed to a Quinnipiac University poll conducted back in March that suggested nearly two-thirds of upper-income Americans were prepared to sacrifice some of their take-home pay to help reduce the deficit. In that poll (www.quinnipiac.edu/x1295.xml?ReleaseID=1438), some 64% of respondents earning more than $250,000 agreed that raising income taxes on themselves and other households making more than $250,000 should be a main part of any government approach to the deficit.

If taxes and insurance premiums are more immediate concerns, some HM observers are eyeing longer trends that could impact the pre-tax pay of the profession. Most hospitalists still earn far less than their specialist counterparts, of course, but increasing demand for hospitalist services has helped fuel a rise in median salaries. Last year, some observers predicted that after an impressive run, annual pay would plateau or even fall, given the current economic uncertainty, tightening profit margins, and assessment that many hospitals run HM programs at a loss.³ And in the current RVU-driven system, the “What have you done for me lately?” mentality can indeed make it difficult for hospitalists to demonstrate a solid return on the investment.

The State of Hospital Medicine report suggests that respondent HM groups have been subsidized by an average of $111,486 per physician FTE (median is $98,253), with the highest numbers in hospital-owned practices. But many experts see a window of a few years in which new healthcare delivery and payment experiments will be trotted out, whether modeled on a bundled system, accountable-care organization (ACO), or other vehicle. Under these models, payment incentives to physicians—and to hospitalists especially—could be fundamentally restructured to better reflect their true contributions as the emphasis on quality and efficiency increases.

Within the next three years, Murer says, hospitalists need to continue to infiltrate inpatient medical services, demonstrate their worth, and show the cost efficiencies that arise from their profession. “I think they’ve got a window of three years to really decide how much of that [inpatient physician] market they will retain,” she says.

Despite the current volatility, both Murer and Dr. Zipper agree that hospitalists are well positioned to take advantage of the coming changes in the healthcare delivery system. But to seize the opportunity, hospitalists must clearly demonstrate the necessity of their services in the emerging models of care and claim an early seat at the table where decisions will be made about how the pot of money is dispersed. Doing so could help resolve one of the most important financial considerations of all: job security. TH

Bryn Nelson is a freelance medical writer based in Seattle.

References

1. Adamy J. Health insurers plan hikes. Wall Street Journal website. Available at: http://online.wsj.com/article/SB10001424052748703720004575478200948908976.html. Accessed Sept. 21, 2010.
2. Cutter S. Look you in the eye. The White House website. Available at: www.whitehouse.gov/blog/2010/09/23/look-you-eye. Accessed Sept. 27, 2010.
3. How will the economy affect hospitalist salaries? MedPage Today website. Available at: www.kevinmd .com/blog/2009/03/how-will-economy-affect-hospitalist-2.html. Accessed Sept. 27, 2010.

Let’s examine a documentation case for hospitalists providing daily care: A 65-year-old male patient is admitted with a left hip fracture. The patient also has hypertension and Type 2 diabetes, which might complicate his care. The orthopedic surgeon manages the patient’s perioperative course for the fracture while the hospitalist provides daily post-op care for hypertension and diabetes.

A common scenario is the hospitalist will provide concurrent care, along with a varying number of specialists, depending on the complexity of the patient’s presenting problems and existing comorbidities. Payors define concurrent care as more than one physician providing care to the same patient on the same date, or during the same hospitalization. Payors often consider two key principles before reimbursing concurrent care:

• Does the patient’s condition warrant more than one physician? and
• Are the services provided by each physician reasonable and necessary?¹

When more than one medical condition exists and each physician actively treats the condition related to their expertise, each physician can demonstrate medical necessity. As in the above example, the orthopedic surgeon cares for the patient’s fracture while the hospitalist oversees diabetes and hypertension management. Claim submission follows the same logic. Report each subsequent hospital care code (99231-99233) with the corresponding diagnosis each physician primarily manages (i.e., orthopedic surgeon: 9923x with 820.8; hospitalist: 9923x with 250.00, 401.1).

When each physician assigns a different primary diagnosis code to the visit code, each is more likely to receive payment. Because each of these physicians are in different specialties and different provider groups, most payors do not require modifier 25 (separately identifiable E/M service on the same day as a procedure or other service) appended to the visit code. However, some managed-care payors require each physician to append modifier 25 to the concurrent E/M visit code (i.e., 99232-25) despite claim submission under different tax identification numbers.

Unfortunately, the physicians might not realize this until a claim rejection has been issued. Furthermore, payors might want to see the proof before rendering payment. In other words, they pay the first claim received and deny any subsequent claim in order to confirm medical necessity of the concurrent visit. Appeal denied such claims rejections with supporting documentation that distinguishes each physician visit, if possible. This assists the payors in understanding each physician’s contribution to care.

Reasons for Denial

Concurrent care services are more easily distinguished when separate diagnoses are reported with each service. Conversely, payors are likely to deny services that are hard to differentiate. Furthermore, payors frequently deny concurrent care services for the following reasons:

• Services exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
• Services by one physician duplicate or overlap those of another provider without recognizable distinction.²

For example, a hospitalist might be involved in the post-op care of patients with fractures and no other identifiable chronic or acute conditions or complications. In these cases, the hospitalist’s continued involvement might constitute a facility policy (e.g., quality of care, risk reduction, etc.) rather than active clinical management. Claim submission could erroneously occur with each physician reporting 9923x for 820.8. Payors deny medically unnecessary services, or request refunds for inappropriate payments.

Hospitalists might attempt to negotiate other terms with the facility to account for the unpaid time and effort directed toward these types of cases.

Group Practice

Physicians in the same group practice with the same specialty designation must report, and are paid, as a single physician. Multiple visits to the same patient can occur on the same day by members of the same group (e.g., hospitalist A evaluates the patient in the morning, and hospitalist B reviews test results and the resulting course of treatment in the afternoon). However, only one subsequent hospital care service can be reported for the day.

The hospitalists should select the visit level representative of the combined services and submit one appropriately determined code (e.g., 99233), thereby capturing the medically necessary efforts of each physician. To complicate matters, the hospitalists must determine which name to report on the claim: the physician who provided the first encounter, or the physician who provided the most extensive or best-documented encounter.

Tracking productivity for these cases proves challenging. Some practices develop an internal accounting system and credit each physician for their medically necessary efforts (a labor-intensive task for administrators and physicians). TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is faculty for SHM’s inpatient coding course.

References

1. Medicare Benefit Policy Manual: Concurrent Care. Chapter 15, Section 30.E. CMS website. Available at: www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed July 9, 2010.
2. Medicare Claims Processing Manual: Physicians in Group Practice. Chapter 12, Section 30.6.5. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
3. Pohlig, C. Daily care conundrums. The Hospitalist website. Available at: www.the-hospitalist.org/details/article/188735/Daily_Care_Conundrums_.html. Accessed July 9, 2010.
4. Medicare Claims Processing Manual: Hospital Visits Same Day But by Different Physicians. Chapter 12, Section 30.6.9.C. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
5. Abraham M, Beebe M, Dalton J, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2010:15.

Let’s examine a documentation case for hospitalists providing daily care: A 65-year-old male patient is admitted with a left hip fracture. The patient also has hypertension and Type 2 diabetes, which might complicate his care. The orthopedic surgeon manages the patient’s perioperative course for the fracture while the hospitalist provides daily post-op care for hypertension and diabetes.

A common scenario is the hospitalist will provide concurrent care, along with a varying number of specialists, depending on the complexity of the patient’s presenting problems and existing comorbidities. Payors define concurrent care as more than one physician providing care to the same patient on the same date, or during the same hospitalization. Payors often consider two key principles before reimbursing concurrent care:

• Does the patient’s condition warrant more than one physician? and
• Are the services provided by each physician reasonable and necessary?¹

When more than one medical condition exists and each physician actively treats the condition related to their expertise, each physician can demonstrate medical necessity. As in the above example, the orthopedic surgeon cares for the patient’s fracture while the hospitalist oversees diabetes and hypertension management. Claim submission follows the same logic. Report each subsequent hospital care code (99231-99233) with the corresponding diagnosis each physician primarily manages (i.e., orthopedic surgeon: 9923x with 820.8; hospitalist: 9923x with 250.00, 401.1).

When each physician assigns a different primary diagnosis code to the visit code, each is more likely to receive payment. Because each of these physicians are in different specialties and different provider groups, most payors do not require modifier 25 (separately identifiable E/M service on the same day as a procedure or other service) appended to the visit code. However, some managed-care payors require each physician to append modifier 25 to the concurrent E/M visit code (i.e., 99232-25) despite claim submission under different tax identification numbers.

Unfortunately, the physicians might not realize this until a claim rejection has been issued. Furthermore, payors might want to see the proof before rendering payment. In other words, they pay the first claim received and deny any subsequent claim in order to confirm medical necessity of the concurrent visit. Appeal denied such claims rejections with supporting documentation that distinguishes each physician visit, if possible. This assists the payors in understanding each physician’s contribution to care.

Reasons for Denial

Concurrent care services are more easily distinguished when separate diagnoses are reported with each service. Conversely, payors are likely to deny services that are hard to differentiate. Furthermore, payors frequently deny concurrent care services for the following reasons:

• Services exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
• Services by one physician duplicate or overlap those of another provider without recognizable distinction.²

For example, a hospitalist might be involved in the post-op care of patients with fractures and no other identifiable chronic or acute conditions or complications. In these cases, the hospitalist’s continued involvement might constitute a facility policy (e.g., quality of care, risk reduction, etc.) rather than active clinical management. Claim submission could erroneously occur with each physician reporting 9923x for 820.8. Payors deny medically unnecessary services, or request refunds for inappropriate payments.

Hospitalists might attempt to negotiate other terms with the facility to account for the unpaid time and effort directed toward these types of cases.

Group Practice

Physicians in the same group practice with the same specialty designation must report, and are paid, as a single physician. Multiple visits to the same patient can occur on the same day by members of the same group (e.g., hospitalist A evaluates the patient in the morning, and hospitalist B reviews test results and the resulting course of treatment in the afternoon). However, only one subsequent hospital care service can be reported for the day.

The hospitalists should select the visit level representative of the combined services and submit one appropriately determined code (e.g., 99233), thereby capturing the medically necessary efforts of each physician. To complicate matters, the hospitalists must determine which name to report on the claim: the physician who provided the first encounter, or the physician who provided the most extensive or best-documented encounter.

Tracking productivity for these cases proves challenging. Some practices develop an internal accounting system and credit each physician for their medically necessary efforts (a labor-intensive task for administrators and physicians). TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is faculty for SHM’s inpatient coding course.

References

1. Medicare Benefit Policy Manual: Concurrent Care. Chapter 15, Section 30.E. CMS website. Available at: www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed July 9, 2010.
2. Medicare Claims Processing Manual: Physicians in Group Practice. Chapter 12, Section 30.6.5. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
3. Pohlig, C. Daily care conundrums. The Hospitalist website. Available at: www.the-hospitalist.org/details/article/188735/Daily_Care_Conundrums_.html. Accessed July 9, 2010.
4. Medicare Claims Processing Manual: Hospital Visits Same Day But by Different Physicians. Chapter 12, Section 30.6.9.C. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
5. Abraham M, Beebe M, Dalton J, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2010:15.

Let’s examine a documentation case for hospitalists providing daily care: A 65-year-old male patient is admitted with a left hip fracture. The patient also has hypertension and Type 2 diabetes, which might complicate his care. The orthopedic surgeon manages the patient’s perioperative course for the fracture while the hospitalist provides daily post-op care for hypertension and diabetes.

A common scenario is the hospitalist will provide concurrent care, along with a varying number of specialists, depending on the complexity of the patient’s presenting problems and existing comorbidities. Payors define concurrent care as more than one physician providing care to the same patient on the same date, or during the same hospitalization. Payors often consider two key principles before reimbursing concurrent care:

• Does the patient’s condition warrant more than one physician? and
• Are the services provided by each physician reasonable and necessary?¹

When more than one medical condition exists and each physician actively treats the condition related to their expertise, each physician can demonstrate medical necessity. As in the above example, the orthopedic surgeon cares for the patient’s fracture while the hospitalist oversees diabetes and hypertension management. Claim submission follows the same logic. Report each subsequent hospital care code (99231-99233) with the corresponding diagnosis each physician primarily manages (i.e., orthopedic surgeon: 9923x with 820.8; hospitalist: 9923x with 250.00, 401.1).

When each physician assigns a different primary diagnosis code to the visit code, each is more likely to receive payment. Because each of these physicians are in different specialties and different provider groups, most payors do not require modifier 25 (separately identifiable E/M service on the same day as a procedure or other service) appended to the visit code. However, some managed-care payors require each physician to append modifier 25 to the concurrent E/M visit code (i.e., 99232-25) despite claim submission under different tax identification numbers.

Unfortunately, the physicians might not realize this until a claim rejection has been issued. Furthermore, payors might want to see the proof before rendering payment. In other words, they pay the first claim received and deny any subsequent claim in order to confirm medical necessity of the concurrent visit. Appeal denied such claims rejections with supporting documentation that distinguishes each physician visit, if possible. This assists the payors in understanding each physician’s contribution to care.

Reasons for Denial

Concurrent care services are more easily distinguished when separate diagnoses are reported with each service. Conversely, payors are likely to deny services that are hard to differentiate. Furthermore, payors frequently deny concurrent care services for the following reasons:

• Services exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
• Services by one physician duplicate or overlap those of another provider without recognizable distinction.²

For example, a hospitalist might be involved in the post-op care of patients with fractures and no other identifiable chronic or acute conditions or complications. In these cases, the hospitalist’s continued involvement might constitute a facility policy (e.g., quality of care, risk reduction, etc.) rather than active clinical management. Claim submission could erroneously occur with each physician reporting 9923x for 820.8. Payors deny medically unnecessary services, or request refunds for inappropriate payments.

Hospitalists might attempt to negotiate other terms with the facility to account for the unpaid time and effort directed toward these types of cases.

Group Practice

Physicians in the same group practice with the same specialty designation must report, and are paid, as a single physician. Multiple visits to the same patient can occur on the same day by members of the same group (e.g., hospitalist A evaluates the patient in the morning, and hospitalist B reviews test results and the resulting course of treatment in the afternoon). However, only one subsequent hospital care service can be reported for the day.

The hospitalists should select the visit level representative of the combined services and submit one appropriately determined code (e.g., 99233), thereby capturing the medically necessary efforts of each physician. To complicate matters, the hospitalists must determine which name to report on the claim: the physician who provided the first encounter, or the physician who provided the most extensive or best-documented encounter.

Tracking productivity for these cases proves challenging. Some practices develop an internal accounting system and credit each physician for their medically necessary efforts (a labor-intensive task for administrators and physicians). TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is faculty for SHM’s inpatient coding course.

References

1. Medicare Benefit Policy Manual: Concurrent Care. Chapter 15, Section 30.E. CMS website. Available at: www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed July 9, 2010.
2. Medicare Claims Processing Manual: Physicians in Group Practice. Chapter 12, Section 30.6.5. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
3. Pohlig, C. Daily care conundrums. The Hospitalist website. Available at: www.the-hospitalist.org/details/article/188735/Daily_Care_Conundrums_.html. Accessed July 9, 2010.
4. Medicare Claims Processing Manual: Hospital Visits Same Day But by Different Physicians. Chapter 12, Section 30.6.9.C. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
5. Abraham M, Beebe M, Dalton J, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2010:15.