Change in VBAC Guidelines

by Clive Riddle, July 22, 2010

The American College of Obstetricians and Gynecologists have just issued new guidelines for a vaginal birth after cesarean (VBAC).  Doctor Richard Waldman, president of The College tells us, "the current cesarean rate is undeniably high and absolutely concerns us as ob-gyns. These VBAC guidelines emphasize the need for thorough counseling of benefits and risks, shared patient-doctor decision making, and the importance of patient autonomy. Moving forward, we need to work collaboratively with our patients and our colleagues, hospitals, and insurers to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate."

Doctor Waldman adds, “Given the onerous medical liability climate for ob-gyns, interpretation of The College's earlier guidelines led many hospitals to refuse allowing VBACs altogether. Our primary goal is to promote the safest environment for labor and delivery, not to restrict women's access to VBAC." The VBAC rate has dropped dramatically during the past 15 years, due to “restrictions that some hospitals and insurers placed on trial of labor after cesarean (TOLAC) as well as decisions by patients when presented with the risks and benefits.”

What has changed? The College guidelines now state women with two previous low-transverse cesarean incisions, women carrying twins, and women with an unknown type of uterine scar are considered appropriate candidates for a trial of labor after cesarean (TOLAC).Proactive counseling is being emphasized, whereby “physicians and patients should consider a woman's chance of a successful VBAC as well as the risk of complications from a trial of labor, all viewed in the context of her future reproductive plans.” They state that women and their physicians may still make a plan for a TOLAC in situations where there may not be "immediately available" staff to handle emergencies, but it requires a thorough discussion of the local health care system, the available resources, and the potential for incremental risk. The College says that restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC. On the other hand, if, during prenatal care, a physician is uncomfortable with a patient's desire to undergo VBAC, it is appropriate to refer her to another physician or center. The new guidelines, Practice Bulletin #115, "Vaginal Birth after Previous Cesarean Delivery," is available in the August 2010 issue of Obstetrics & Gynecology.

Here’s three statistical items supplied by the College:

  • U.S. Cesarean delivery rate: 5% in 1970; 31% in 2007.
  • U.S. VBAC rate:  5% in 1985; 28% in 1996, 8.5% in  2006
  • Risk of uterine rupture during a TOLAC: —between 0.5% and 0.9%

Much Ado about Peer Review

By Clive Riddle, July 14, 2010

JAMA’s current issue features the article: Physicians' Perceptions, Preparedness for reporting, and Experiences Related to Impaired and Incompetent Colleagues, by Catherine M. DesRoches, DrPH [JAMA. 2010;304(2):187-193. doi:10.1001/jama.2010.921]. The article presents survey results regarding physician peer monitoring and reporting, which nationally polled “2938 eligible physicians practicing in the United States in 2009 in anesthesiology, cardiology, family practice, general surgery, internal medicine, pediatrics, and psychiatry. Overall, 1891 physicians (64.4%) responded.”

The survey asked "In the last three years, have you had direct, personal knowledge of a physician who was impaired or incompetent to practice medicine in your hospital, group, or practice?" The study found that:

  • 64% agreed with the professional commitment to report physicians who are significantly impaired or otherwise incompetent to practice.
  • 69% said they were prepared to effectively deal with and report impaired colleagues in their medical practice
  • 36% do not feel obligated by professional commitment to report such physicians
  • 17% had direct personal knowledge of a physician colleague who was incompetent to practice medicine in their hospital, group, or practice.
  • Of the 17% with this knowledge, 67% reported this colleague to the relevant authority.
  • Physicians working in hospitals or medical schools; and physicians with l0 years or fewer experience, were most likely to report impaired or incompetent colleagues.
  • Pediatricians and family practice physicians were the least likely to say they felt prepared to deal such colleagues; anesthesiologist and psychologists apparently felt most prepared
  • Most cited reasons for taking no action was (1) belief that someone else was taking care of the problem (19%) belief that nothing would happen as a result of the report (15%) and fear of retribution (12%)

The study concluded that “physicians support the professional commitment to report all instances of impaired or incompetent colleagues in their medical practice to a relevant authority; however, when faced with these situations, many do not report” " Matthew Wynia, director of the AMA Institute for Ethics, comments that “I don't think there's any excuse for less than 100 percent of physicians holding true to these ideals." A free JAMA podcast by JAMA’s editor in chief discussing the survey as part of commentary on the current issue is available for download.

Headlines regarding the article accentuate the minority percentage of physicians who do not report:

Los Angeles TimesStudy shows doctors often eschew watchdog role

CBS NewsMany Docs Don't Blow Whistle On Colleagues

The Washington PostDo doctors rat on each other?

This is certainly not the first study to address the issue of physician peer review. Some recent examples include California’s legislatively mandated study, which was released by sub-contractor Lumetra as the Comprehensive Study of Peer Review in California: Final Report, July 31, 2008 which found it was “apparent is that the present peer review system is broken for various reasons and is in need of a major fix”; from Public CitizenHospitals Drop the Ball on Physician Oversight , released May 27, 2009 which concluded a “lack of detection and widespread under-reporting to the National Practitioner Data Bank raise serious questions about hospital peer review.” Modern Physician magazine, in their June 8, 2009 issue ran a lengthy article discussing the debate about the Public Citizen report .

Here’s a few observations for consideration on this issue:

  • Regulated peer review focuses on the hospital setting, and is built on a 20th century model in which a greater degree of care was delivered in a hospital setting. Physician behavior and actions outside the hospital setting are typically under-addressed by state or federal regulations
  • Physicians, excel as they do as a profession, are still human, and subject to similar mindsets, pressures and workplace issues as other professions. Who really thinks any other profession subject to peer review would have better reporting outcomes?
  • Accountability for professional competence in any profession is much stronger when there is an organization structure that the professional is employed by, or financially belongs to. Organization accountability can be an even stronger continuous force for some than regulatory or even ethical accountability.  Thus large medical groups, medical schools, VA, group health plans and other such entities tend to have less of a problem in this area than open medical staffs. Note the survey findings that “physicians working in hospitals or medical schools; and physicians with l0 years or fewer experience, were most likely to report impaired or incompetent colleagues.” As younger physicians have a greater tendency to practice in larger medical groups and organizations, this issue should experience improvement over time.

Primary Care Access During this Decade

by William J. DeMarco MA CMC, President, Pendelum Health Corporation, July 1, 2010

In the current issue of MCOL’s Thought Leaders newsletter, I was asked: How big of an issue will primary care access become during this decade- what are its implications- and what initiatives (such as medical homes, retail clinics, employer on site clinics, etc) if any, do you think will bring about improvement?" Here is what I replied:

What we continue to learn is that primary care doctors graduate with hopes of becoming the family practice doctor in a smaller town, something we desperately need, but the economics do not permit this new MD to move forward with their career. Because of the large loans and debts of medical school and subhuman conditions of an internship doctors really start out very poor and in debt. The actual earning of a salary does not occur for several years and the salaries for primary care are not rising as fast as specialist salaries. So many are forced to decide to sub-specialize in a more lucrative area where they can make the dollars they want as surgeons of super specialists and join a private practice as a respected member of the medical group.

This drives demand for primary care but until the salary cap blows off or the economics of medical school costs are altered we see the logical overpopulation of specialty practitioners while PCPs are treated as an aside by both hospital’s and physicians. When one calculates the revenue from referrals to specialist and hospitals that a single PCP makes the numbers can be astounding. True the specialists has a higher revenue per patient but the volume of PCP referrals to specialists and hospitals are far greater yet hospitals have been able to keep PCP compensation low and , in some markets, threaten PCPs that they must join the ranks of employed physician or be replaced.

In this vacuum we are seeing innovation. First by remaking primary care as a retail almost impulse buy the for the consumer retailers like Walgreen’s, Target, CVS Wal-Mart and K Mart and even some grocery store chains have brought Primary care to the patient. This is packaged as a Nurse practitioners and offered for common un-complicated illnesses which , for some, is less expensive and less intrusive than the Emergency room and certainly easier than waiting for 4 to 6 weeks for a PCP visit . While this transition occurred Nurse Practitioners and Physicians Assistant salaries shot up some 27% over their colleagues who were still stuck in public health or working as a medical assistant in a practice where physicians did not make full use of their talents.

As Dr Don Berwick ,Nominated CMS chief, has said the best way to manage costs in the delivery of care is to have the most efficient person downstream from the doctors do the work. So you have NPs PAs and RNs doing more of what they are trained to do thereby making the PCP more productive at less cost. In this regard the Employer owned medical practice is gathering steam as more and more employers see the value of designing benefits around the use of early detection and health promotion and less use of unnecessary specialty care unless the PCP has approved it as necessary. A well equipped PCP group practice with NPs and PAs seeing the right patients at the right level of service can be very successful in attracting volume because of its convenience and flexibility for follow-up.

The cost of such a medical group owned by an employer can quickly be paid back in terms of savings to emergency rooms, early detection of serious disease and better coordination of admissions and discharges to avoid readmissions and reduce length of stay for illness or injury. This kind of commitment by management also can create a positive attitude in the employees who feel their employer is not only offering them a way to pay for care through an indemnity insurance plan but also guaranteeing them a place to get it in the workplace. This guarantee is becoming more and more important as less primary care are available and few insurance companies will pay for ER rooms to replace PCP visits.

These various roles of Primary care emphasize team work and coordination of care. Some of the retail clinics are picking up on this as are the hospitals who once feared these competitors have encourage discussion and referrals to assure continuity and communication between patient and practitioners as well as practitioners to practitioners dialogue. Turning this delivery system on its head by having Primary care driven medicine is slowly at work at the federal level with ACOs and MA plans requiring PCP advocates be assigned or selected by each patient. This constant pressure of demand for PCP will, we believe, force hospitals and clinics to rethink their compensation strategies but also put the pressure back on policymakers to revisit funding for primary care spots in rural and urban settings by subsidizing broadly the medical school experience.  By encouraging more newly graduating Physicians, Physicians Assistants and Nurse Practitioners to advance their education with a promise of being that family practice doctor we all want and need


196 Pages of the Patient’s Bill of Rights

by Clive Riddle, June 24, 2010

This week, HHS, Department of Labor, and Department of The Treasury issued regulations to implement the Patient’s Bill of Rights referenced under the Patient Protection and Affordable Care Act.  A Fact Sheet summarizing these regulations was posted on   The 196 page Interim Final Rules have already been posted and the Federal Register will post the Rules on Monday (June 28th.

President Obama remarked on the status of the Act, and the new Bill of Rights, in a White House Event, noting “The Departments of Health and Human Services, Labor and Treasury are issuing new regulations under the Affordable Care Act that will put an end to some of the worst practices in the insurance industry, and put in place the strongest consumer protections in our history -- finally, what amounts to a true Patient’s Bill of Rights. This long-overdue step has one overriding focus, and that’s looking out for the American consumer.  It’s not punitive.  As I said when I met with the insurance executives, it’s not meant to punish insurance companies.  They provide a critical service.  They employ large numbers of Americans.   And in fact, once this reform is fully implemented a few years from now, America’s private insurance companies have the opportunity to prosper from the opportunity to compete for tens of millions of new customers.  We want them to take advantage of that competition.”

As implementing regulations from the Act, there is no new policy here, just the creation of the document set forth in the Act with operational details. So in reading a summary of the Bill of Rights, you will certainly get déjà’ vu because all this was well covered in highlights of provisions of the Act itself.  Of course, the fun will be pouring through the 196 pages of details.

Never the less, here is a summary of what the detailed regulations address: Effective on or after September 23: insurance companies are barred from:


  1. Imposing pre-existing condition exclusions on children
  2. Rescinding or taking away coverage based on an unintentional mistake on an application
  3. Setting lifetime limits on coverage
  4. Restricting use of annual limits on coverage.
  5. Restricting choice of the primary care doctor or pediatrician within a plan’s provider network
  6. Requiring a referral for women to can see an OB-GYN
  7. Requiring prior approval before seeking emergency care at a hospital outside the plan’s network.

(Items 5-7 apply to plans that are not grandfathered as defined in the regulations)


An interview with Brian C. Smith on Prospective Overpayment and Fraud Prevention

by Clive Riddle, June 18, 2010 

This week, MCOL conducted a podcast interview with Brian C. Smith, an Executive Vice President with HealthCare Insight as a part of the 2010 Predictive Modeling Web Summit. Brian addressed a predictive approach to health care fraud and abuse. Below are some selected statements from Brian during the interview. 

“It’s a sad fact that particularly such areas as Durable Medical Equipment and HIV testing are wide open for abuse. For example, in South Florida with over a couple of years of focus just on the DME problem, they've seen the amount of DME submitted bills go down $1.7 billion dollars, meaning that upwards of 50-60% of prior claims were pure fraud.” 

“If you're going to defraud a payor, you're going to go where the easiest, most likely, and highest dollars are, and those are in federal and states programs like Medicare and Medicaid, as opposed to commercial health insurers who are investing a fair amount of dollars and really getting after fighting fraud and abuse.” 

“The Federal side has about a $1.8 billion investment in fraud, waste and abuse on an annual basis that primarily goes to the DOJ Office of Inspector General and Medicaid Fraud units, and has recaptured in the $2.5 - 2.8 billion range. In contrast, the Blues, for example, which have reported recently that across their 100 million members, that their 39 plans represent, they recovered $516 million, which works out to $0.43 pmpm. Apply that to the much larger federal population, and it would be a much higher yield. “ 

“We're seeing our customers move away from the idea of pay and chase [retrospective identification of overpayments or fraud] to a prospective basis. We're looking at literally all of their claims, upfront, overnight. We have history of flagged providers as well, from a couple of years for up to five years, and we can identify various schemes and profiles of these providers, and stop these payments up front. That produces a tremendously higher yield, and those dollars never leave the claims shop. The Federal side has generally not embraced this technology. “ 

“The predominant tactic today, particularly on the Federal side, is pay and chase. The Federal side uses fiscal intermediaries who generally have no incentive, or capability, for that matter, to stop the payment before it leaves the door. Many self insured administrators are also just doing a cursory job at looking backwards, retrospectively, at these schemes. The best, most efficient way, is when clients and payor customers, before they send these payments out, look at patterns with these particular providers, comparing those providers to other specialists within that provider range. What you can see is that these particular providers are often unbundling their services for what should be a global procedure, and bill continually in a manner fraught with unbundling, overcoding, upcoding, and incorrect coding. That's a pattern. Our customers are stopping those claims from being paid, and have the claims clinically verified. Once our system identifies a pattern, we have clinical investigators that drill down into those particular providers, and provide a detailed report with recommended actions to take.” 

“1 to 2 percent of the 1 million+ providers might have been involved in actual fraud at some point in time. There's far more dollars in the abuse area, where there's aggressive billing habits, compared to normal billing patterns, where the particular providers are 2 to 3 standard deviations more aggressive in how they bill, with areas such as modifier abuse with the codes. That's where we see hundreds and hundreds of millions of dollars of abuseful practices.” 

Click here to listen to the full podcast interview with Brian C. Smith, Executive Vice President, Sales, HealthCare Insight, discussing "Prospective Overpayment and Fraud Prevention.