Category: Daily News

More than half of heart patients in a new study made mistakes taking their medications or misunderstood instructions given to them after being discharged from the hospital. Those with the lowest “health literacy” were among the most likely to make the risky errors, highlighting the importance of healthcare professionals making sure their instructions are clear and of patients being sure they understand what they need to do after they get home, the study authors say. “Some errors have the potential to be harmful to patients,” said lead author Dr. Amanda Mixon, a hospitalist with the VA Tennessee Valley Healthcare System in Nashville. “Thousands of patients are discharged home with medications every day. Knowing which patients are at risk of medication errors after patients go home can help inpatient providers counsel patients about their medications before they go home,” added Mixon, who is also affiliated with Vanderbilt University.

According to the story in Reuters Health, past research suggests that an individual’s health literacy, the ability to interpret and act on health information, is a strong predictor of whether they will correctly follow instructions for their own care. Overall, 20 to 30 percent of prescriptions are never filled, and 50 percent are not continued as prescribed, according to the U.S. Centers for Disease Control and Prevention.

To assess what factors might influence whether heart patients will follow their care instructions correctly after leaving the hospital, Mixon’s team recruited 471 people hospitalized for heart failure, heart attacks and related conditions, then discharged from the hospital. The participants’ average age was 59 and just under half were women. Every participant took a seven-minute health literacy test to gauge their understanding of health information as well as a short numeracy test to measure basic math skills.

The researchers contacted the patients by telephone two to three days after they left the hospital and compared the medications on the discharge list from their doctors to what the patients said they were taking. When someone said they were taking a medication not on the list, or forgot to mention one that was on the list, it was counted as an error. If a patient didn’t know the purpose, dose or frequency of a medication, it was classified as a misunderstanding. Failure to refill a prescription, discontinuing use of a medication against a healthcare professional’s orders or not being aware of a medication were also counted as errors.

More than half – 242 of the 471 patients – had at least one discrepancy between the medications they reported taking, and the ones on their discharge list. Over a quarter left out one or more medications on their list and more than a third were taking something that was not on the list. And 59 percent of patients had a misunderstanding of the purpose, dose or frequency of their medications.

Participants who scored highest on the math skills test were about 23 percent less likely than those who scored lowest to add or omit medications, the researchers report in Mayo Clinic Proceedings. People with the highest health literacy scores were about 16 percent less likely to make an error compared to those who scored lowest. And women were about 40 percent less likely than men to make a mistake. Single people were almost 70 percent more likely than people who were married to make errors. Older age and worse cognitive function also predicted higher odds of having an error.

“It’s a powerful study in that it helps to define some of the things we assume, but haven’t been able to fully understand,” said Dr. Benjamin Brooke, a surgeon and professor at the University of Utah School of Medicine in Salt Lake City, who was not involved in the study. “I think this says that we need to do a better job of understanding a patient at the time of discharge, what are their risks of having a post discharge adverse event,” he told Reuters Health.

This study should help workers’ compensation case managers focus on a strategy that should help better post surgical outcomes.

The Department of Industrial Relations and its Division of Workers’ Compensation posted a progress report on the department’s implementation of Senate Bill 863, the 2012 law which makes wide-ranging changes to California’s workers’ compensation system.

The report, “SB 863: Assessment of Workers’ Compensation Reforms,” describes improvements made as well as the challenges remaining to fulfill the law’s intent to improve benefits to injured employees while containing costs. SB 863 became law on Jan.1, 2013, but not all provisions were effective immediately, and some aspects are still going through the rulemaking process.

:DIR took a balanced approach to putting SB 863’s reforms into practice,” said DIR Director Christine Baker. “The priority was to increase the benefits in 2013, reduce frictional costs and implement the cost savings efficiencies through regulations, a process that started as soon as the law was signed. We have laid the groundwork for the next stage of improvements and expect more gains in the years ahead.” Key findings of the report include:

1)  Although SB 863 successfully trimmed three percentage points off the rate increase, employers still had to endure an increase of more than 10% in their workers’ compensation costs. Insurance prices had already begun to rise in 2012. After SB 863 was passed, the Department of Insurance adopted a minimum pure premium rate for Jan. 1, 2013, which was up 11.3% from the rate one year earlier. If SB 863 had not been enacted, indications are that the rates would have increased by 14.3%.
2)  Permanent disability benefits increases are now in effect. It is too soon to determine the net effects, primarily because it takes up to two years or more for permanent disability to be determined.
3)  SB 863 strengthened California’s self-insurance marketplace, thanks to the greater oversight authority provided to DIR’s Office of Self Insurance Plans over self-insured employers. The reforms lowered the rate of defaults thereby reducing costs to all remaining self-insurers. To date, no defaults have occurred in self-insured entities since SB 863 regulatory changes went into effect.
4)  SB 863 reduced ambulatory surgery center (ASC) facility fees from 120% to 80% of Medicare’s hospital outpatient fee schedule. The average amount paid per ASC episode in the first six months after the change in fee schedules was 26% lower than in the year before the change took effect.
5)  SB 863 amended the inpatient fee schedule by repealing the separate reimbursement for spinal hardware. The average amount paid per episode of the spinal surgery involving implantable hardware declined by 56% after the separate reimbursement (duplicate payment) for spinal hardware was repealed.
6)  The lien filing fee halved the number of new liens being filed. In the first year the filing fee was in effect, 213,092 liens were filed, down from 469,190 in 2011, a greater than 50% reduction. This represents a cost savings of an estimated $270 million per year in litigation costs to California employers and insurers.
7)  Medical costs appear to be down: Preliminary data from WCIRB indicate that the estimated ultimate medical loss per lost-time claim is down 1.3% from calendar year 2012 to 2013. However, because the estimate is based on historical trends and adjusters’ predictions of what their cases will cost over the lifetime of the case, it is a weak performance indicator of the workers’ compensation system after the extensive reforms brought about by SB 863.
8)  The Independent Medical Review (IMR) process is heavily used: approximately 185,000 IMR applications have been filed to date. The qualified medical evaluator (QME) process that IMR replaces costs on average $1,653 per QME request, at least three times higher than the administrative cost of an IMR. An IMR costs $420 to process, down from $560 initially, and the cost will go down further starting in 2015.
9)  Ten sets of cost-saving regulations have been enacted, and additional regulations are in process.
10)  More than 80 percent of IMR determinations uphold the utilization review (UR) finding that the treatment requested is not medically necessary. Pharmaceuticals are the most common IMR request, and narcotics are the most common type of pharmaceutical requested.

“One of the key improvements of the reforms was to improve the delivery of appropriate medical care to injured workers through an independent medical review process that is transparent and consistent and uses evidence-based medicine,” said Dr. Rupali Das, DWC Medical Director. It is still too early to gauge the overall effect of SB 863 reforms. Revisions to the lien filing procedures, as well as the conflict of interest statute and the fee schedule changes, are expected to help reduce fraudulent behavior in the workers’ comp system.

The progress report is posted on the DIR website.

Three Orange County residents allegedly defrauded insurers by submitting bills for more than $50 million for medically unnecessary procedures, federal prosecutors said Wednesday in a 15-count indictment.

Charged were Vi Nguyen, 31, of Placentia (10 counts of mail fraud); Theresa Fisher, 44, of Tustin (five counts of mail fraud); and Lindsay Hargraves, 30, of San Pedro (two counts of mail fraud). Nguyen and Fisher were “consultants,” Hargraves a marketer. All three were arrested on July 1 before the criminal complaint was unsealed. They were all released on bond. They are to be arraigned on July 28.

Prosecutors claim the defendants used marketers to lure patients to a surgery center in Orange, known at various times as Empire Surgical Center, Vista Surgical Center and Princess Cosmetic Surgery. These were different business names for the same surgery center, consisting of one consultation office and one surgical suite, located at 1310 W. Stewart Drive, Suites 309 and 310, Orange, California. “The marketers told patients that they could use their union or PPO health insurance plans to pay for cosmetic surgeries, which are generally not covered by insurance,” the US. Attorney’s Office said in a statement announcing the indictment.

At the center, prosecutors said, the patients were told they could get free or discounted cosmetic surgeries if they submitted to “multiple, medically unnecessary procedures that would be billed to their union or PPO health care benefit program.” The health care programs were funded by the International Longshore and Warehouse Union and Pacific Maritime Association Welfare Plan as well as private programs such as Anthem Blue Cross Blue Shield and Horizon Blue Cross and Blue Shield of New Jersey. The plans generally did not cover cosmetic surgery.

The unnecessary procedures typical were endoscopies, colonoscopies and/or cystoscopies. The plastic surgeries included tummy tucks, falsely billed as hernia repairs; nose jobs, falsely billed as deviated septum repairs; breast surgeries and liposuction, prosecutors said. Empire, Vista, or Princess also allegedly billed union and PPO health care benefit programs for procedures that never were performed on patients.

Progressive Medical Inc. and PMSI Inc., two workers compensation pharmacy benefit managers that merged in October, will begin operating under the name Helios in August, according to a statement issued Tuesday. Helios is based in Memphis, Tennessee, and employs more than 1,400 workers nationwide, including at Progressive Medical’s Westerville, Ohio, location, PMSI’s Tampa, Florida, office and offices in Salt Lake City and Price, Utah, according to the Helios website. The rebranding will be fully effective Aug. 18.

“Our new name is the outcome of a thorough and deliberate process that involved a great deal of research,” the company said in a statement posted online. “We considered a large number of concepts and in the end, selected Helios for its strong representation of our brand, the vigor in which we operate, and overall positive disposition.”

“While our name and look are changing, our commitment to doing what’s right is unchanged,” said Tommy Young, Co-CEO. “We will continue to provide exceptional service, proactively share intelligence with our clients to ensure they have the best information to manage their businesses, and deliver innovative solutions to effectively drive down costs and improve both clinical and financial outcomes.”

The name was chosen because it embodies the vision, values, and personality of the organization and captures the legacies of the two companies, according to H. Barry Jarnigan, Chief Marketing Officer. “Helios captures the energy, strength, reliability, and consistency of our company as well as our passion and dedication for providing exceptional, accountable service.”

Helios will be a new name in the workers’ compensation and auto no-fault markets; however, it will be built upon Progressive Medical and PMSI’s legacy of innovative products and exceptional service. Along with the name, the company will unveil a new logomark at the Workers’ Compensation Institute’s annual conference beginning August 18.

The Division of Workers’ Compensation is now accepting applications for the Qualified Medical Evaluator examination set for October 18.

The Application for Appointment as QME and all required documentation must be reviewed and approved by the DWC before a physician can be registered for the exam, (Title 8, California Code of Regulations §§10, 11). The application must be postmarked by September 11, 2014, in order to qualify for this exam. Qualified registrants will receive by e-mail/mail, a confirmation letter along with a Candidate Information Booklet.

Physicians who wish to take the exam on October 18, 2014, must submit a completed original Application for Appointment as Qualified Medical Evaluator (QME Form 100, Rev.10/2013)  Physicians who submitted an Application for Appointment as a QME form 100, (rev 10/2013), for the last exam April 12, 2014, are not required to submit another application, but must send all other documentation/fee required and Registration for the QME Competency Examination (QME Form 102, Rev. 2/09).

All physicians are required to pay a non-refundable/non-rollover $125.00 fee to sit for any upcoming QME examination. (Title 8, California Code of Regulations § 11(f)(2)). Before appointment as QME, the physician shall complete a 12 hour course in disability evaluation report writing, approved by the Administrative Director. (Labor Code § 139.2)