Health professionals report CME bias
The commercial funding of continuing medical education (CME) and the potential for bias is of great concern for a significant number of healthcare practitioners and researchers, many of whom admit to being unwilling to pay higher fees to eliminate or offset commercial funding, according to a report in the Archives of Internal Medicine, (Arch Intern Med 2011;171:840-846).
Organizations including the Institute of Medicine, the American Association of Medical Colleges, and the American Medical Association, have indicated wanting further decreases in the role that pharmaceutical and medical device manufacturer's play in directing CME.
From January through June 2009, a group led by Jeffrey A. Tabas, MD, from the University of California, San Francisco surveyed attendees at CME courses delivered by the International AIDS Society USA (IAS-USA), a nonprofit organization. In total, 770 attendees (a 57% response rate) completed the 22-item survey, which concentrated on beliefs about commercial funding and the possibility for bias, willingness to offset the cost of commercial support, knowledge about the costs of producing CME programs, and demographic information.
Participants included physicians, nurses, nurse practitioners, physician assistants, and persons with PhDs or other academic degrees. "Our two main outcome variables were dichotomized as follows: one, agreed or strongly agreed that raising the registration fees is an effective way to decrease commercial support versus not, and two, agreed or strongly agreed that commercial support for live CME should be eliminated versus not," the authors of the survey explained in Archives of Internal Medicine.
Eighty-eight percent of responders reported that commercial support of a CME activity introduced the potential for bias. This perception of bias also was directed toward CME faculty who receive support from industry.
In general, participants who suspected industry bias in CME were more likely to favor reducing or abolishing such funding. But the majority of the group would opt against raising registration fees or offering fewer topics or speakers, among other measures.
Specific programs enhance hospice care
Study confirms hospice not necessarily targets rich
Developing a business model or marketing strategy that includes services focused on specific patient populations does not necessarily mean that a hospice is targeting higher revenue patients, as implied in a study recently published in the Journal of the American Medical Association (JAMA),1 but it often represents a response to a community need, says Carole Fisher, president and chief executive officer of Nathan Adelson Hospice, a not-for-profit hospice in Las Vegas. "One way to improve care is by addressing specific patient needs," Fisher says.
Although hospices accept all appropriate patients according to Medicare's Conditions of Participation, some hospices are developing disease-specific programs to provide more focused care for some conditions. "We developed a program to address the needs of patients with pulmonary diseases such as chronic obstructive pulmonary disease [COPD]," says Fisher. "COPD patients are an underserved population in our area, and offering services that are specific to their needs was the right thing to do."
Mark M. Murray, president and chief executive officer of The Center for Hospice Care, a not-for-profit hospice in Mishawaka, IN says, "My hospice has specific programs for Alzheimer's, congestive heart failure, and COPD," These conditions are non-cancer diagnoses for which it is more difficult to predict length of service and which typically result in longer lengths of service, Murray says. "It is a good business model that results in our hospice providing service to a variety of patients who benefit from hospice care," he adds.
Murray was surprised that the JAMA article used the care of dementia patients as an indicator that for-profit hospices were selecting patients who required less expensive care. "Dementia-related deaths increased by 46% from 2000 to 2006, which means this is a population that hospices should be serving in increasing numbers," he says.
The key to providing good hospice care is to look at the needs of your community, Murray suggests. "This study did not look at local needs that drive the programs you develop or the patients you serve," he adds. "We developed our COPD program because a high percentage of our community members smoke and develop lung diseases," he explains.
Programs that provide care to patients in nursing homes are also important, regardless of the hospice's tax status, says Joan M. Teno, MD, MS, professor of community health and medicine at the Warren Alpert School of Medicine of Brown University, Providence, RI, and associate medical director for Home and Hospice Care of Rhode Island, a not-for-profit hospice in Providence. Hospices and nursing homes can work together to provide the best care possible at the end of life, she says.
"Not only can hospice staff and volunteers provide the hospice services directly to nursing home patients, but they can also serve as consultants and educators to support the nursing home staff," says Teno. "The nursing home will have patients who don't qualify for hospice care but may need palliative care, and a partnership with a hospice can benefit those patients as well," she says. For all areas of healthcare to provide the best care possible, it is necessary to look for innovative ways to partner with each other, she suggests.
While hospice originally was focused on care of cancer patients, the increase in the number of non-cancer diagnoses has changed the needs of hospice patients, says Fisher. She adds, "At one time, hospices tried to be everything to everybody, but now we see patients with a wide range of diseases that increase the need to offer some disease-specific programs."
- Wachterman MW, Marcantonio ER, Davis RB, et al. Association of hospice agency profit status with patient diagnosis, location of care, and length of stay. JAMA 2011; 305:472-479.
Hospice cap deficits = managing case mix
A good balancing act reduces the risk
Balancing your case-mix to avoid hospice cap deficits doesn't mean discharging patients or admitting patients who don't meet hospice criteria, warns Kyle Terry, MBA, consultant and principal at Hospice CAP Consultants in Owasso, OK.
"Although a balance of short- and long-term patients is the best strategy to minimize your risk of receiving a repayment demand letter from Centers for Medicare and Medicaid Services (CMS) based upon the hospice cap, it is important to follow admission criteria guidelines issued by CMS," he says.
After the hospice manager has evaluated the cap deficit risk, the manager should look at the types of patients your hospital typically admits and also the referral sources, Terry suggests. "Then, look at where the marketers are going," he says. "Generally, oncologists will refer shorter term patients and family practitioners will refer longer term patients, many of whom may be in nursing homes," he explains. To ensure a balanced case-mix, make sure your marketers are visiting all types of referral sources, he adds.
The hospital manager should monitor admissions on a monthly basis with a focus on how the patient mix affects cap deficit or surplus, says Terry. By watching on a monthly basis, the hospital manager will have an opportunity to make changes and redirect marketers in a timely manner, according to Terry.
Tricks such as not filing a claim with CMS until after the start of a new fiscal year won't work, warns Terry. "The calculations are not based upon the date the claim is received. They are based upon the dates on which services were provided," he says.
Staff members, not just marketers, should be included in discussions about the need for a variety of patients, says Terry. "Staff members are sources of referrals also because their friends and families are likely to choose the hospice because they know someone who works there," he says. "I was always very open with my staff about the reality of the hospice cap and how we could work together to avoid repayment demands."