Redefining the war on obesity 

Physicians play a central role: helping the patient redefine success. Encouraging overweight and obese patients to sustain a modest, but realistic weight loss of only a few pounds can bring significant health improvement even in the absence of much cosmetic change.

 
AMA President Nancy H. Nielsen, M.D.

Value-based health care reform  

The health care overhaul debate appears to have moved beyond how to expand health insurance to cover all Americans and how to reduce health care spending, as two separate questions. The focus now is working out details of how to structure incentives appropriately to optimize cost, quality and access.

Reducing administrative costs  

Health plans, provider groups and the information technology sector are collaborating on ways to standardize some administrative tasks such as credentialing and patient benefit determination, and to expedite other tasks by replacing paper-based data exchange with electronic tools.

POS President Jon B. Tucker, M.D.

MCARE abatement stuck in stalemate  

The connection of medical liability premium subsidies to health insurance expansion has led to a political impasse, which could cost Pa. health care providers billions of dollars over the next ten years and severely impair efforts to recruit physicians to the state for years to come.

Growing role of nurse practitioners  

Reality has outpaced the debate over nurse practitioner autonomy and scope of practice, given the intensifying shortage of primary care providers and health care workforce demands that place a premium on collaboration with physicians.

Anthony Aquilina, D.O., MBA

Physician “report cards” – ratings of physician quality and efficiency made publicly available by health plans and other entities – are undergoing major transformation, as key developments are spurring improvements in substantive validity and methodological transparency.

Concerns about time, cost and liability persist, while use of electronic communication raises issues including privacy and security regulations under HIPAA, efficiency, efficacy, care coordination, care documentation, practice marketing potential, and the patient-physician relationship.

Rusty Holman, M.D.

Appraising the value of hospitalists  

While the hospitalist model has gained widespread acceptance within the health care delivery system, research remains surprisingly inconclusive as to whether it has improved the efficiency and quality of patient care, or lowered costs; while concerns remain about its potential erosion of continuity of care, the physician-patient relationship, and the supply of office-based general internists.

Physician websites evolve  

While these Web 2.0 technologies facilitate rapid access and exchange of medical information, democratizing the promulgation of that information requires more vigilance to vet its credibility and potential bias, as sources may be anonymous and/or have commercial ties to industry that are not immediately apparent.

Karen Rizzo, M.D.

Growing uninsured strains safety net   

As the number of uninsured grows, the strain on the health care safety net intensifies. Inherent weaknesses of that safety net – maintaining adequate resources and coordinating patients’ specialty care needs – may be reaching a critical point.

Reducing health care disparities   

Definitive causes of persistent health disparities remain elusive, but recent research from key agencies sheds new light on the issue, as well as which models of intervention may hold the most promise for closing the health status gap, and those models are being applied at the state and local level.

Amy Waterman, Ph.D.

Impact of medical errors on physicians   

The problem is more prevalent than one would expect, while adequate support services for physicians are often unavailable, and physicians do not use available services for a variety of personal and professional reasons.

Physician-insurer relations evolve   

Although still defined partly by acrimonious confrontation over reimbursement issues, the relationship has seemingly taken on a more cooperative style, as illustrated by several recent developments affecting Pennsylvania and New Jersey physicians.

Reform focus shifts to health courts   

The health court concept is being treated with a new level of seriousness, enjoys growing support from new quarters, and now occupies a conspicuous place in medical liability reform policymaking.

Physician pay-for-reporting launched   

Many physicians may find the PQRI appealing, as they stand to gain extra reimbursement for reporting data that they may already capture in their patients’ clinical charts, although participation will likely entail workflow changes, and few expect the 1.5 percent bonus to cover a practice’s additional cost for capturing and reporting the data.

Medicare's pay-for-performance   

Experiences from this project are expected to help shape the nationwide value-based purchasing program authorized under the 2006 Deficit Reduction Act and scheduled to be launched in fiscal year 2009.

Physician-hospital gainsharing   

A practice that violates the federal anti-kickback statute, the Stark physician self-referral law and the civil monetary penalties provision of the Social Security Act is gaining legitimacy as a catalyst for physician-hospital collaboration and clinical quality improvement.

Averting a Medicare meltdown   

There appears to be a consensus among stakeholders and analysts that the current reimbursement mechanism is ineffective at holding down costs, incapable of improving quality of care, inequitable to physicians, and injurious to Medicare’s balance sheet.

Implementing a medical home

A wholesale change in the way that primary care is organized, delivered and reimbursed is being promoted by three primary care specialty societies, being tested in Pennsylvania and New Jersey, and gaining clout in the form of a federal demonstration project.

Role of medical board discipline   

As Pa. reforms the disciplinary activities of its medical boards, several issues emerge, including what constitutes a realistic expectation for the boards’ role in improving quality and reducing medical errors and malpractice claims in the state.

Appraising PHC4's infection report   

Given the report’s methodological limitations, its accompaniment by new research minimizing the importance of those limitations, and its data displayed in a format that seems to encourage inappropriate comparisons of one hospital’s numbers to another hospital, the meaning and significance of the report become complicated questions.

Pa. expands health care access   

Recent events in Pennsylvania suggest that the state is poised to tackle the problem of its growing uninsured population.

Angioplasty waiver compromise   

Pressured by litigation and looming legislation, DOH has agreed to resolve the impasse by offering waiver extensions to hospitals doing elective angioplasty without open heart surgery programs that do one of three things: join a national randomized trial, join an in-state registry, or agree to a supervisory and cross-training arrangement with a tertiary hospital to oversee quality.

Candidates square off on health care - Part 1 

The Republican candidate for U.S. Senate from Pennsylvania answers our questions.

Candidates square off on health care - Part 2 

A health care position paper from the Democratic candidate for U.S. Senate from Pennsylvania.

Restricting drug company influence 

Small gifts, modest meals and drug samples from pharmaceutical reps still get physicians to prescribe the newest and often most expensive drugs, according to a recent critique that some hospitals are taking seriously.

Price transparency expanding 

Price transparency raises several questions, including what form the data should take, for whom is the data really useful, what the “well-informed consumer” will do with his or her knowledge, whether disclosure will result in lower prices, and whether it could have unintended negative consequences.

Physician-patient communication 

Recent developments are driving a paradigm shift in medical education: training medical students, residents and practicing physicians in “best practice” communication skills, restoring the value of empathy and rapport-building between physicians and patients.

QIOs under fire, face reform 

There is scant evidence that QIO interventions drive quality improvement, and QIOs appear to meet their beneficiary complaint review obligations poorly. Those findings were affirmed by an Institute of Medicine investigation, which will guide government reforms.

State of Pa.'s mental health care 

The report identifies strengths and weaknesses in a three-tiered system of state hospitals, county-level services and non-profit community-based providers in a uniquely diverse state of two large urban centers and the nation’s largest rural population.

Responding to physician shortage 

Recent AAMC and ACP reports address various manifestations of physician shortage and offer suggestions to academic institutions and policymakers. Medical schools around Pa. have begun to respond.

Medicaid reform time again 

The medical community and other stakeholders believe that Pa.’s current Medicaid program structure is unsustainable, that mere fiscal tinkering will not fix a broken system, and that major structural reform is required.

Pa.'s hospital-acquired infection battle 

While hospitals have for years included infection control as part of their quality improvement programs, release of the PHC4 reports has called into question the adequacy of those efforts by tallying HAI frequency, decrying their cost, and heightening public awareness of their existence.

Pharmacist scope of practice expansion 

Pa. is in the final phases of expanding the scope of what pharmacists can do in collaboration with physicians, including managing drug therapy in an institutional setting and administering injectable medications at the retail level, while retail pharmacy chains are expanding their patient services and are poised to open primary care centers staffed by nurse practitioners.

Turning a corner on Pa.'s malpractice crisis 

Four recent developments in the public and private malpractice insurance sectors spell good news for physicians and have some industry officials declaring that Pa. is beginning to turn a corner on its malpractice crisis.

Are health savings accounts the answer? 

Proponents hope HSAs will reduce over-utilization, increase access to health care, improve the physician-patient relationship, and lower overall health care costs. Critics argue that the plans jeopardize patients’ access to quality care and may actually end up increasing health expenses in the long term

Some stakeholders regard the draft regulations as representing bold and long-overdue change that is urgently needed to keep pace with a health care delivery landscape that has evolved significantly over the past 20 years, while others regard them as overly prescriptive and intrusive.

Malpractice crisis erodes access 

Recent studies found that "high-risk" patients may be not be getting the care they need because of defensive medicine and other physician practice changes induced by the threat of liability.

Cardiac program raises quality questions 

A demonstration project that permits community hospitals without open heart surgery programs to perform elective therapeutic cardiac catheterizations highlights the tension between enhancing access by patients in underserved regions to potentially lifesaving medical services, while ensuring that proliferation of highly specialized clinical services does not erode quality of care or endanger patients.

Ambulatory surgical centers proliferate 

While they offer physicians convenient and potentially lucrative practice opportunities, ASCs appear to be hurting hospitals’ margins, and are fueling concerns that their rapid growth may be outpacing quality oversight and regulation.

Patient Safety Authority data emerges 

Some interesting details are presented in the PSA’s 2004 Annual Report, although interpretation of the data is not straightforward, and critics argue that the PA-PSRS system has other significant shortcomings.

Growth of electronic medical records 

Obstacles to acquiring EMRs are softening, while recent developments may spur skeptics and fence-sitters to consider making an investment in EMR sooner, rather than later.

Overcoming pain management obstacles 

Clinical obstacles and fear of legal and regulatory sanction may still prevent physicians from prescribing medically appropriate pain treatment, while federal guidance for appropriate prescribing of pain medication has taken a false start.

Medicaid reform in Pennsylvania 

Cutbacks come as good news to no one, and they will inevitably erode patient care and negatively affect the health of some of Pa.’s poorest and most frail citizens.

Changes in practice patterns are being fueled by malpractice costs and are impacting patient care throughout Pa. , reducing neurosurgeon supply, making recruitment difficult and increasing patient travel times and office appointment wait times.

Assessing disease management in PA 

While disease management programs in Pa. appear to be expanding, a firm assessment of the impact of these programs – on patients, on physicians and on health care costs – lags considerably behind that growth.

Certificate of Need reinstatement 

Legislators, under pressure to provide economic relief for employers and to ensure quality health care, are for the first time in eight years giving serious consideration to reinstating the now-defunct Certificate of Need statute.

United HealthCare's Alan Glenesk

Blues' market dominance challenged 

As the clout of surplus scrutinizers grows and health plan competition intensifies, Pa.’s Blue Cross insurers are now being pressured on both ends simultaneously.

The Highmark program, which institutes new rigorous quality standards, will mean fewer imaging providers, fewer imaging centers, stricter referral procedures, and presumably lower costs.

David L. Merideth, M.D., J.D., M.B.A.

Lawsuits indict hospital charity care 

The lawsuits further complicate hospitals’ struggle to balance legal, ethical and pragmatic obligations to provide charity care.

Community hospitals reappraise destiny 

Particular market variables are dictating whether a community hospital will merge with an academic medical center, for-profit hospital chain, other community hospitals, or go it alone, with each bringing advantages and disadvantages, both for the institution and the physicians who practice there.

Stephen Foreman, Ph.D., J.D., M.P.A.

Physician exodus questioned 

Some legislators have assumed a stance of outrage and are demanding that the medical community be held accountable for its alleged misinformation campaign.

Medication safety efforts advance 

Various agencies are endorsing IT-based medication error reduction systems, which is likely to spur movement by Pa. hospitals to invest in computerized prescriber order-entry (CPOE) or point-of-care prescription bar-coding systems.

University of Pennsylvania Health System's 
Garry Scheib

Obstetrician scarcity in Pennsylvania 

Availability of obstetrical services has indeed continued to dwindle in various regions of the state, putting serious stress on the health care delivery system and potentially endangering the health of women and infants.

Malpractice mediation poised to expand 

As a tool to settle litigation between plaintiffs and defendants, mediation can reduce the number of malpractice cases that go to trial and avoid the risk of high jury awards for plaintiffs, while also greatly expediting case resolution and saving on protracted legal costs for plaintiffs and defendants.

Susan Anderson

Drug coverage expand as costs rise 

This embarrassment of riches has led some to wonder whether the Medicare expansion will ultimately hurt Pa. by pre-empting the popular PACE and PACENET programs, as well as how the expansions will be sustainable in light of the skyrocketing increase in prescription drug costs.

Malpractice reforms ineffective  

In the wake of fresh premium increases and heavy lobbying last year for tort reforms that stalled in the Pa. Legislature, physicians may look to what reforms have passed in Pa., and whether they will bring relief any time soon.

Long-term reforms stalled in 2003  

Many physicians may wonder what happened to the clout they projected eight months ago at the Code Blue Protests - having since seen little visible progress toward malpractice reform goals and nearly losing MCARE abatement relief, which looked like it was in the bag early on.

Role of patient satisfaction  

As physicians and hospitals experience growing pressure to increase the quality of their outcomes, enhance the safety of their patients and lower the cost of their care, analysts expect greater attention and scrutiny to be given to the accountability function of patient satisfaction scores, and to ways in which patient satisfaction measurement can be further integrated into an overall measure of clinical quality.

CMS' Stuart Guterman

Payors expand quality incentives  

Expansion of pay-for-quality incentive programs takes clinical guidelines to a new level and raises questions about how they may transform the medical profession and patient care.

Businesses and consumers – despite perennial accolades and praise for Pennsylvania Health Care Cost Containment Council’s mission with each published report – have scarcely made use of the data in their purchasing and provider selection decisions over the years, while physicians and hospitals have become the chief users of the Council’s data for quality improvement efforts.

Three health insurance companies have come forth with lawsuit settlement proposals promising more favorable reimbursement practices and significant changes in their reimbursement policies and procedures, which physicians had tried to get them to implement, without success, through contract negotiations and through legislative channels.

Physician shortage in Pennsylvania?  

There is still no consensus among researchers on two key questions: (1) Is the number of Pa. physicians dropping? and (2) At what point would that lead to a physician shortage?

Pa.'s bioterrorism preparedness  

A combination of federal funding earmarked for bioterrorism preparedness and innovative research and development has brought important enhancements to Pa.’s ability to detect and respond to mass casualty events. The availability of a stronger and more responsive public health infrastructure brings to physicians perhaps the strongest-ever bond between their public and private health care systems.

Physicians stand united in protest

The Code Blue Emergency protest overwhelmingly succeeded in achieving its primary goal of publicity: educating the public about tort reform, about why their physicians are clamoring for caps on noneconomic damages and attorney fees, and providing a glimpse at what will happen to their access to medical care if reform does not come soon.

Malpractice Task Force 
      Chairman Abraham Gafni 

With little progress on the passage of its short-term proposal in the Pa. General Assembly and the release of long-term recommendations not including caps on malpractice awards, physicians’ focus had already shifted away from the Rendell task force to other, more aggressive means of remedying the situation

Slow start for Patient Safety Authority  

One year after Act 13’s passage, the Patient Safety Authority is still working to find an outside vendor to handle medical-error data analysis, while growing criticism of the authority's pace of operation highlights how high medical-error reduction efforts have risen on the state legislative agenda.

Martin Bergman M.D.

Physicians drop health insurers  

Some physicians, squeezed by declining reimbursement rates and escalating malpractice costs, are starting to selectively contract with commercial insurers or Medicare and are finding that they can thrive, let alone avoid crippling their practice.

Tobacco allocation getting results  

By FY 02-03, Pennsylvania will have spent nearly a billion dollars from its share of the national tobacco settlement on a broad array of initiatives to improve the health of Pennsylvanians. Despite a somewhat rocky start, the state’s spending on these initiatives is in full swing and several initiatives are producing tangible results in key health care venues, including health insurance, medical research, care of the elderly, smoking cessation, hospital enhancements and nursing school enrollment.

Gail Warden

Bush to push sweeping health reform  

The reforms seek to substantially redesign America’s health care delivery and financing system—from changing the way primary care is delivered and records are kept, to covering the uninsured, to shifting medical liability burdens off the shoulders of physicians.

Efforts to avert malpractice meltdown  

Even though three significant tort reform measures have been enacted in the past nine months, the crisis of affordable and obtainable medical malpractice insurance has worsened. Various entities have recently begun significant efforts to avert a massive crisis.

Capital Blue Cross President James M. Mead

Forces challenge Pennsylvania Blues  

A number of emerging trends signal a potential threat to the Blues’ unquestioned market power, including high medical costs aggravated by Pa.’s medical malpractice crisis, high-profile scrutiny of the Blues' surplus levels, plans by the FTC to beef up investigations of health insurers, and competition between Blues plans in central Pa.

Through organized communication networks with their colleagues, fund-raisers and financial contributions, and direct communication with their patients about candidates in the upcoming elections, physicians are no longer taking a back seat to their opponents in making their political clout known.

HAP President Carolyn F. Scanlan

The law's impact may not be all positive for physicians and may expose their personal assets to risk when a jury award exceeds their malpractice insurance coverage and plaintiff attorneys have nowhere else to turn for recovery.

Regulating CT screening in Pa.  

Private entrepreneurs throughout Pa. who have set up Computed Tomography facilities have recently been dealt a serious regulatory setback. The Pa. Dept. of Environmental Protection has prohibited patient scans without a physician referral and the Pa. Dept. of Health has issued a warning to consumers about limiting unnecessary exposure to radiation produced by these scans. These developments raise questions and concerns about government's role in regulating the practice of medicine, potentially stifling medical innovation.

Pa. Physician General Robert Muscalus

Payor-providor conflict escalates  

The structural dynamics and market pressures that produced this escalation may help to clarify why it has happened, whether it can be avoided and how it may play out in the future.

Ritual praise and criticism of the report raises a number of important questions about what the data mean; whether the data are used; what can be done to make their interpretation more appropriate and useful for hospitals, physicians, patients, purchasers, health insurers and regulators.

Impact of Pa. malpractice law  

Act 13, the medical liability reform signed into law on March 20, has brought Pa.’s medical community significant and sorely-needed professional liability tort reforms. But immediate urgencies have had a head-start on the new law, as the cost medical malpractice coverage continues to surge and access to coverage continues to worsen.

Malpractice reform and patient safety became inextricably combined in the new legislation, but the relationship between error reduction measures and malpractice litigation is complex, with the two frequently at odds with each other.

UPCI Director Ronald B. Herberman, M.D., (left) & WPA Director of Oncology Norman Wolmark, M.D.

Cancer center competition intensifies  

UPMC’s and West Penn Allegheny’s initiatives will significantly expand the availability of cancer care technology and resources in the region and both seek to increase clinical cancer trial participation by patients from community hospital settings. At stake are cancer patient referral patterns by physicians, as well as the ability of both systems to recruit top oncologists.

Telemedicine prospects in Pa.  

Fettered by high infrastructure costs and by reimbursement and marketplace obstacles, telemedicine appears to have fallen far short of its promise in Pennsylvania. A series of new developments may jumpstart its use in this state.

MDs challenged on disability insurance  

In the wake of a massive financial shake-up of the disability insurance industry a few years ago, the industry has undergone significant consolidation, policy benefits for physicians have eroded and physicians are experiencing benefit delays and denials, with some resorting to costly and protracted litigation against their insurers.

Appraising the Children's-UPMC merger  

The Pa. Attorney General's Office has finally sanctioned the merger between Children's Hospital of Pittsburgh and UPMC Health System, producing a consent decree that spells out the rules for the merger and the anticipated effects it will have on health care delivery, access and competition in the region.

Medical Resources on Bioterrorism

CDC bioterrorism site: www.bt.cdc.gov
Government resources, role and recommended protocols.

Johns Hopkins Center for Civilian Biodefense:
www.hopkins-biodefense.org
Comprehensive site includes diagnostic criteria and treatment guidelines for anthrax, botulism, smallpox and plague.

U.S. Army infectious disease site:
www.usamriid.army.mil/education/bluebook.html
Medical management of biological casualties handbook.

Medical responses to bioterrorism  

The need to firm up plans for quickly detecting, reporting, treating and containing any outbreaks of particularly rare and deadly diseases promises to be a mighty test of the city, state and national public health infrastructure. An assessment of the labyrinth of preparedness structures offers a context for understanding where practicing physicians fit in and how they can most effectively represent the interests of their patients and their country.

Stakes of Pa. Supreme Court election  

An election to fill a vacant seat of the Pennsylvania Supreme Court could tip the balance on the Court in physicians’ favor--a Court that has been the most important obstacle to meaningful tort reform.

Judge Michael Eakin

Aetna CEO John W. Rowe, M.D

Aetna’s intentions, if actualized, would signify a remarkable transformation in the managed care industry. Those intentions appear to have been partially realized, although physician experience has been mixed. Nevertheless, Aetna’s changes would seem to be dictated by current marketplace trends and may offer a glimpse of how managed care will be shaped in the years to come.

Pa.'s senior Rx coverage crisis  

An estimated 33 percent of Pa.’s seniors have no prescription drug coverage and the state’s model program assisting the low-income elderly with the purchase of prescription drugs--PACE--is in financial trouble. As Pa. legislators review cost containment proposals--including mandating discounts on retail drug prices beyond current rebates available to PACE; instituting a drug formulary; requiring therapeutic generic substitution for most medications; and requiring "step therapy" protocols--there are some avenues physicians can pursue to help their elderly patients afford their prescriptions.

Pa. Secretary of Aging 
Richard Browdie

There are indications that physicians and hospitals in western Pa. are struggling to realize a viable financial balance of the reimbursement-minus-overhead equation. A radiologist shortage appears to exist in the region, as reimbursement rates may be failing to keep and attract physicians, and some hospitals are eliminating risky services such as obstetrics in order to trim expenses.

Malpractice reform gains momentum  

The physician campaign to redress Pennsylvania's medical liability crisis has secured a key ally, as the respective boards of the PMS and HAP have agreed upon a multiyear agenda to address the problem.

Carol E. Rose, M.D.

Sr. Catherine Manning

Although Saint Vincent and Hamot continue to operate joint services, Hamot’s recent decision to pull out of a trauma services joint venture has further soured the institutions’ relationship, leaving physicians wondering how the ramped up competition will affect them.

CME evolves beyond lectures  

While some defend the importance and appropriateness of traditional CME program formats, a variety of innovative CME programming, some involving the latest web-based technology, is increasingly being made available to physicians.

Barbara E. Barnes, M.D., M.S.

J. Scot Chadwick

Fate of joint negotiation legislation  

While the future of antitrust waiver legislation is unclear, movement at the federal and state levels indicates that the campaign is not over, although it will take some time to achieve the momentum that was lost last year.

Academic medicine's adaptions  

The relationship between medical schools and teaching hospitals is being put to the test as economic pressures are forcing medical institutions in Pa. to explore new ways to maintain vibrant research and teaching programs.

Jack Wilberger, M.D.

CAT Fund Director John H. Reed

Malpractice awards surge in Pa.  

While physicians in western and central Pa. are partially subsidizing the medical malpractice morass in the eastern part of the state, Philadelphia physicians without claims against them are paying twice as much as their colleagues in other parts of the state, raising questions as to the most equitable way to shoulder the burden.

Post-CON cardiac surgery in Pa.  

Even after four years, surprisingly little data exists on what impact the lapse of Certificate of Need is having on the volume, cost and quality of invasive cardiac care in Pa.

Pa. physician flight or oversupply?  

As health plans and physicians debate whether Pa. is suffering from a shortage or oversupply of physicians, the assessment by physicians, recruitment firms and health economists suggests that a practice environment dominated by managed care can have serious impacts on both physician distribution and the practice of medicine. An analysis of two seemingly incommensurate alternatives turns up issues far richer than a mere arithmetic assessment would suggest.

Candidates' health care proposals  

Gore’s focus is on spending more to expand existing government programs, while Bush favors spending less and relying more on market-based reforms. Issues include the Campbell bill, tort reform, medical research finding, HMO patient bill of rights, expanding health care access to the uninsured and Medicare reform.

PMSLIC President Sarah H. Lawhorne

Pa.'s malpractice premiums soar  

A marked increase in frequency and severity of claims, insolvencies of two malpractice insurers and recent financial hits taken by two key players in the Pa. market have produced double-digit premium hikes. The future of the CAT Fund is also uncertain.

Pa.'s tobacco settlement allocation 

With few days left in the legislative session for this year and the lack of consensus among legislators, prospects for passage this year seem slim. Various sectors of Pa.'s health care delivery and advocacy sectors continue to lobby legislators in the hope of crafting modifications to the Ridge tobacco settlement allocation proposal. The outcome of these activities will ultimately impact Pa.'s health care system in a variety of significant ways.

Settlement Chronology

April 1997 - Pa. becomes 24th state to file lawsuit against tobacco companies.
November 1998 - Forty-six states, including Pa., reach $206 billion joint settlement with tobacco companies.
December 1999 - Pa. receives first settlement payment of $123 million.
January 2000 - Pa. receives settlement payment of $142 million.
January 2000 - Gov. Ridge issues settlement allocation plan.
April 2000 - Pa. receives settlement payment of $198.5 million.
June 2000 - Pa. General Assembly adjourns for summer recess without appropriating settlement funds.

Managed care contracting strategies 

A physician practice’s size, niche or geographic location could make meaningful contract negotiation possible. When a dominant health insurer tries to introduce a major new variation of its existing plans, or when smaller health plans look for an expanded foothold in their market, still more contractual opportunities may present themselves to the prepared physician who scrutinizes key contract provisions.

Act 68 regulations raise concerns 

Although the statute and regulations promise a number of improvements for patients and physicians, a number of concerns remain, among them, that Insurance Dept. regulations leave enough slack to make it difficult for physicians to use the statute’s timely payment provision systematically and that health plans can apparently define medical necessity any way they wish.

Rep. Nicholas A. Micozzie

Rep. Pat Vance

Nursing scope of practice regulations 

More than 20 years after Pa. passed a law allowing certified registered nurse practitioners to prescribe and dispense medications without a physician’s signature, the state boards of nursing and medicine have ratified regulations that will put the law into effect. A catalyst for the approvals, House Bill 50, is presumed dead but its implications are expected to live on.

M.D. joint negotiation bills advance 

Legislation that would allow independent physicians to negotiate collectively with health plans is enjoying a groundswell of support, both at the federal and state levels, and appears to indicate a sea change in the politics of medicine.

Congressman Tom Campbell

Alan H. Gradman, M.D.

Scrutinizing episodic care payments 

It will be up to physicians to determine how to adopt episode of care reimbursement: whether forging it themselves or seeking avenues of unity to help shape the models imposed on them by insurers.

Impacts of error reduction initiatives 

In addition to actually reducing adverse events, error reduction initiatives could have impact on the way health care systems are organized and care is delivered, on physicians’ clinical decision-making authority, on patient choice of physicians and hospitals, and on medical malpractice rates and lawsuits.

David M. Lawrence, M.D.

Loren Roth, M.D., MPH

Is integrated delivery sustainable? 

Integrated delivery systems, once touted as the only means of hospital survival, face rough times, while many independent hospitals have faired reasonably well in the midst of shrinking reimbursements.

Transitioning to private practice 

Entering private practice from an employed setting confronts physicians with a barrage of duties, details and challenges that, if handled properly, can yield a viable transition.

Larry Jones, M.D.

• Washington State statute allows self-employed physicians to negotiate jointly with health plans over contractual issues not including fees.

• Texas law allows joint physician negotiation with health plans over fees and other contractual issues, while prohibiting strikes.

• Congressional bill would grant antitrust exemptions to self-employed health care professionals to negotiate collectively with health plans, while prohibiting strikes.

• Three physician joint negotiation bills introduced in the Pennsylvania General Assembly, with two others expected to be introduced shortly.

Physician antitrust waivers gain momentum 

Existing state laws that permit private physicians to negotiate jointly with health plans over contract issues free of antitrust obstacles are beginning to bear fruit, while a federal bill offering even more negotiating latitude for physicians seems likely to be amended and moved for a vote. In Pennsylvania alone, three antitrust waiver bills for health care professionals have been introduced in the state Legislature, while two more are expected to be introduced shortly.

Are housestaff organizations next? 

Efforts to unionize or organize residents and fellows could mean dramatic changes for housestaff at Pennsylvania institutions and fresh opportunities for medical and labor organizations looking to boost membership.

John Paletta, M.D.

Physician unions propagate in Pa. 

Two AFL-CIO affiliates gained footholds among Pa. physicians in past two years, while the Pennsylvania Medical Society has geared up to assist physicians in forming collective bargaining units.

Collective bargaining vote challenges AMA leadership

A great deal has been made about the AMA’s vote, ranging from those who view the decision as marking the zenith of physicians’ resolve to those who believe that the ethos of the medical profession is imperiled by associating itself with the working-class interest politics of labor unions.

Physician unions take root in Pa. 

The AMA’s vote to form a national labor organization punctuated a three-year identity crisis for physicians and marks a decisive turning point by putting the stamp of approval on physician unions. In the first of a two-part series on the roots of physician unionization in Pa., organized labor sparks a conflagration within organized medicine in Philadelphia but fails to generate much heat in Allegheny County.

Serious reform proposals emerge 

While incremental solutions have been adopted or are under consideration for a variety of problems in the current health financing system, a surprising convergence between critics has emerged on the point that nothing short of fundamental change will significantly improve the situation.

Annals of Internal Medicine
Editor Frank Davidoff, M.D.

Legislative Initiatives

• Washington state measure implemented in 1995 allows competing physicians to negotiate jointly with health plans over contractual issues not including fees.

• Texas Legislature passed measure last month to allow physicians to negotiate jointly with health plans over contractual issues including fees.

• Pennsylvania Medical Society is drafting legislation similar to the Texas bill for possible introduction this fall.

A radical and little-known approach to redress the problem of monopolistic health plan behavior has quietly been in effect in Washington state since 1995, has just passed the Texas legislature and is seriously being considered for introduction in Pennsylvania as early as this fall.

Lung association civil war in Pa. 

The national American Lung Association has become embroiled in a conflict with its former allies by fracturing Pennsylvania’s strong, local ALA affiliates in favor of a state-level operation.

Christine Weaver

AGH Medical Staff President Christopher Bonnet, M.D.

MD impact of Allegheny purchase 

While West Penn and Allegheny physicians favor this union, they do have concerns about financing, physician involvement in governance and effects on patient referral patterns.

IPAs confront market challenges 

Preserving autonomy has not come cheaply or easily, and independent physician groups have met with mixed success.

Stanley Pomarantz, M.D.

Managed care showdown in Texas; 

After years of escalating hostility and mistrust, two large integrated physician organizations have terminated their HMO contracts with Aetna U.S. Healthcare.

Expanding non-MD scope of practice; 

In a health care arena that continues to seek frugal alternatives to costly medical treatment, physicians can expect this year to see a number of significant efforts in the Commonwealth to expand the medical scope of practice of non-physicians.

Contested Areas

• Pa. Board of Medicine declares nurses in Highmark's Blues on Call telephone triage program to be engaged in the practices of medicine.

• Joint Boards of Medicine and Nursing issues draft regulations that would allow certified registered nurse practitioners to prescribe drugs and to diagnose and manage patients.

• Pa. Department of Health issues regulations expanding the list of drugs optometrists may prescribe independently from physicians.

• Bill that would authorize pharmacists to administer drugs and order and perform laboratory and other diagnostic tests.

• Bill that would grant psychologists hospital admitting and discharge privileges, as well as medical staff and committee membership.

PMSLIC President Sarah H. Lawhorne

Malpractice insurance market evolves 

Larger companies have moved in to pick up available market share while other companies have sought to strengthen their market position by selling to larger entities or converting from mutual to public companies.

Appraising Pa.'s health regulation

Apparent absence of protective intervention by Pennsylvania’s Health and Insurance departments in the realms of hospital systems and health insurance have prompted nontraditional players to step in to fill the vacuum.

Pa. Attorney General Mike Fisher

Rethinking MD contract renewals

Physicians are faced with questions about whether or not to renew their employment contracts and the hurdles that must be surmounted with each decision.

Physician fate in hospital systems

Hospital system expansion may inevitably lead to reduced physician influence over his or her practice, even where a physician practices, for whom and at what level of income.

Allegheny General Hospital
Medical Staff President
Richard Ray, M.D.

Highmark President John S. Brouse (left) and UPMC President Jeffrey A. Romoff are apparently the only major players
left standing after a fenzied period of market-driven medicine.

MDs confront Highmark and UPMC

As Highmark and UPMC cast antitrust aspersions at each other, physicians explore ways to confront the extraordinary market power of both entities.

HMO law gets mixed reviews

The law contains much that is praiseworthy, but a closer look reveals important limitations and omissions of which physicians should be aware.

Documentation and coding tools

Given ample reason to be concerned about their documentation and coding habits, physicians need to examine the strengths and weaknesses of various products and services available to expedite those tasks. Documentation efficiency aside, one might also contemplate how useful these systems are to actual patient care.

Teaching hospital audits hit region

Officials at University of Pittsburgh Medical School are angered over what they say has been an unfair application of vague federal guidelines regarding physician presence and imprecise evaluation and management codes.

Does standardization equal quality?

Some view practice guidelines as merely attempts to legitimate cost cutting measures, while others see them as attempts to improve outcomes and reduce costs. Is physician resistance based on professional integrity or professional arrogance?

Malpractice coverage in jeopardy

Malpractice insurance worries are back: What to do when your insurer folds? What is surprising is the crucial role the CAT Fund will play and the potential for uncovered liability despite its protection.

Key Recommendations

• Provider grievance process to check against termination without cause and adverse utilization decisions.

• Provider accreditation and financial incentive disclosure.

• Expanded definition of primary care provider (PCP) to include certified registered nurse practitioners, physician assistants and certified nurse midwives.

New managed care proposals

DOH managed care policy recommendations may spell good and bad news for physicians. The definition of Primary Care Practitioner may expand to nurses, physician assistants and nurse midwives. Other recommendations institute standards for provider credentialing, managed care network capacity, provider grievance procedures and utilization review.

Physicians slam market-driven medicine

A physician-drafted Call to Action is intended to spark a revolt against market-driven health care. Ad Hoc committees in Philadelphia and Pittsburgh will pursue the manifesto proscribing for-profit takeovers of health care institutions.

Physician unions gain steam

While the debate continues over whether it is prudent for physicians to join unions, recent developments indicate that a growing number of physicians are choosing to muster down that path with the hope of protecting their professional autonomy from policy dictates of hospital networks and health insurance companies. Local and national developments are examined.

Blocking the merger juggernaut

Hospital or insurance company consolidations often find physicians as anxious spectators rather than engaged advocates. Three Pennsylvania cases demonstrate the potential for regulatory intervention to slow or thwart those consolidations, and outline the physician’s role in that intervention.

PA Attorney General Mike Fisher

Health Secretary Daniel Hoffman

Work groups mull managed care regulation

Having implementing a massive managed care work group project, the Pennsylvania Department of Health is moving the state closer toward updated managed care regulation. Invited to the table are players from dozens of organizations—insurers, providers, consumers and business—to produce regulatory or legislative recommendations to the Governor.

Insurer MD credentialing rationed

Least among the worries of physicians has been whether or not they can join a major health insurance panel. Until now. Highmark’s recent credentialing practices leaves little doubt that it plans to be more restrictive in admitting physicians to its managed care networks. Physician recourse is limited.

Recent events, both in Pennsylvania and nationally, indicate a trend toward increased HMO risk of being sued for medical malpractice. That may not be good news for physicians, however, as HMOs go on the offensive. A recent case illustrates the potential dangers.

As employment becomes a more dominant setting for physicians, what will become the dominant image for what it means to be a physician in our society? Two competing visions are analyzed in the face of some sobering trend data.

Children’s Hospital has apparently drawn its own line in the sand to forestall contracting boundaries expected between the two competing hospital networks—Tri-State Health System and Pyramid Health.

Oxford Health Plans’ initiatives to manage patient populations by specialty teams and nurse practitioners challenge the traditional primary care physician gatekeeper model of managed care. One of the experiments is being tried in Pennsylvania; the other may not be far behind.