Appendix 2
BREAKOUT ON WHO IS KEEPING US HONEST
The Joint Commission on Accreditation of Healthcare Organizations conducts regular inspections and accreditations in order to help "laboratories improve quality, reduce costs, demonstrate accountability, and increase participation options in managed care and other contractual arrangements - all critical elements for long-term success in a rapidly changing health care marketplace." Accreditation by the Joint Commission is an essential seal of approval for major hospitals. Its web site (www.jointcommission.org) is an immense resource.
The College of American Pathologists, based in Northfield, Illinois, currently accredits over 6000 laboratories, with "deeming authority" from the CMS. Its mission is to "represent the interests of patients, the public and pathologists by fostering excellence in the practice of pathology and laboratory medicine worldwide." Its full members include almost 16000 pathologists, and almost 80 percent of pathology residents are junior members. The College offers proficiency exercises, offers numerous educational and management seminars, and issues several important publications. Its political action committee, PathPAC, works to assure that legislators serve the best interests of the public and pathology. In order to maintain accreditation, surgical pathology laboratories undergo inspection every two years by experienced teams sent out by the CAP. The CAP may also respond to complaints about laboratory services. Its web site is at www.cap.org
The American Medical Association. In the United States, health care insurers annually process over 5 billion payment claims, and Medicare and other health insurance programs require standardized coding systems for orderly processing of these claims. The codes used by surgical pathologists are geared around what is known as Current Procedural Terminology (CPT). This numeric CPT coding system is maintained by the American Medical Association, and is designed to identify medical services and procedures furnished by physicians and other health care professionals, who use the CPT codes to bill public or private health insurance programs. The AMA website is at www.ama-assn.org
The Centers for Medicare and Medicaid Services is a U.S. federal agency that administers the Medicare and Medicaid programs. Among its goals is the promotion of the fiscal integrity of its programs and the preservation of accountability for the manner in which public funds are spent. Medicare resources provide essential support for graduate medical education in the USA, and make both direct and indirect payments to hospitals that train residents in approved medical residency training programs. The calculation of these payments is affected by the number of full-time equivalent (FTE) residents that a hospital is allowed to count. Generally, the greater the count, the greater the payment made by Medicare. Indirect payments from Medicare are higher for teaching than non-teaching hospitals because of increased (or inefficient) testing of patients by residents and the relatively higher complexity of cases at teaching centers. CMS is therefore interested in knowing how much of a physician's time is spent with residents in non-billable teaching activities. CMS also monitors the use of CPT codes for potentially fraudulent activity. Since the CMS has authorized the CAP and state departments of health to conduct inspections on its behalf, CMS may decide to audit those inspections at any time. Physicians in teaching hospitals are required by CMS to submit, on a quarterly basis, an account of their daily work-related activities over a two-week period, in half hour increments. (Appendix 1). The CMS website is at www.cms.hhs.gov
The Accreditation Council for Graduate Medical Education governs the accreditation of medical training programs in the United States. It sets standards for residency programs and offers advice in related areas. The ACGME empowers Residency Review Committees to inspect training programs in all medical disciplines, including pathology, to ensure that hospitals provide sufficient infrastructural support, so that residents may undergo meaningful educational experiences and are not excessively deployed in purely service capacities. In recent years, the ACGME has developed and mandated the use of a structured method for assessing the actual competence of trainees as they proceed from year to year (see Part 3). Its website (www.acgme.org) is richly informative.
The Office of Professional Medical Conduct in New York State investigates complaints about physicians and their associates. This office serves the Board for Professional Medical Conduct and comprises about 200 physicians and lay members. It offers services to the public and the health care community via its web site (www.health.state.ny.us/nysdoh/opmc/fac.htm).
The New York State Department of Health inspects clinical laboratories in the state every two years, requires pathologists to undergo regular proficiency testing in cytology, and may perform an inspection in response to a complaint. Its website is at www.health.state.ny.us
The United States Department of Health and Human Services. Under the Privacy Rule established by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), all "individually identifiable health information" that is held or transmitted in any form by a "covered entity" or its business associate is protected. An important goal of the Privacy Rule is to ensure that individual health information is properly protected, while allowing the information to flow in such a manner that promotes high quality health care. Therefore, all health care providers, regardless of size, who electronically transmit health information in connection with certain transactions, are covered entities and may be held accountable under HIPAA. The website is at www.hhs.gov
The National Practitioner Data Bank (NPDB). The text in this section is taken virtually verbatim from the home page of the NPDB, which states that the U.S. Congress enacted legislation that led to the formation of the NPDB because it believed that problems with medical malpractice litigation had become significant and nationwide, that there was a need to improve the quality of medical care, and that the efforts required to address these issues were greater than any individual State could undertake. The intent was to improve the quality of health care by encouraging State licensing boards, hospitals and other health care entities, and professional societies to identify and discipline those who engage in unprofessional behavior; and to restrict the ability of incompetent physicians, dentists, and other health care practitioners to move from State to State without disclosure or discovery of previous medical malpractice payment and adverse action history. Adverse actions can involve licensure, clinical privileges, professional society membership, and exclusions from Medicare and Medicaid.
The NPDB is primarily an alert or flagging system intended to facilitate a comprehensive review of health care practitioners' professional credentials. The information contained in the NPDB is intended to direct discrete inquiry into, and scrutiny of, specific areas of a practitioner's licensure, professional society memberships, medical malpractice payment history, and record of clinical privileges. The information contained in the NPDB should be considered together with other relevant data in evaluating a practitioner's credentials; it is intended to augment, not replace, traditional forms of credentials review. The NPDB website is at www.npdb-hipdb.com
Healthcare Integrity and Protection Data Bank (HIPDB). This, too, is taken from the home page of the HIPDB. The Secretary of the U.S. Department of Health and Human Services, acting through the Office of Inspector General (OIG), was directed by the Health Insurance Portability and Accountability Act of 1996 to create the Healthcare Integrity and Protection Data Bank (HIPDB) to combat fraud and abuse in health insurance and health care delivery. Health care fraud burdens the nation with enormous financial costs and threatens the quality of health care and patient safety. Estimates of annual losses due to health care fraud range from 3 to 10 percent of all health care expenditures - between $30 billion and $100 billion based on estimated 1997 expenditures of over $1 trillion.
The HIPDB is primarily a flagging system that may serve to alert users that a comprehensive review of a practitioner's, provider's, or supplier's past actions may be prudent. The HIPDB is intended to augment, not replace, traditional forms of review and investigation, serving as a supplement to a careful review of a practitioner's, provider's, or supplier's past actions. The HIPDB may be accessed via the website of the NPDB.
Occupational Health and Safety Administration (OSHA). From OSHA's web site (www.osha.gov/oshinfo/mission.html), the following: "OSHA's mission is to assure the safety and health of America's workers by setting and enforcing standards; providing training, outreach, and education; establishing partnerships; and encouraging continual improvement in workplace safety and health. OSHA and its state partners have approximately 2100 inspectors, plus complaint discrimination investigators, engineers, physicians, educators, standards writers, and other technical and support personnel spread over more than 200 offices throughout the country. This staff establishes protective standards, enforces those standards, and reaches out to employers and employees through technical assistance and consultation programs."
New York State Legislature. Each State has an interest in the health and welfare of its citizens, expressed, for example, in the following preamble to Section 2 of the New York State Medical Care Facilities Finance Agency Act (1973): The protection and promotion of the health of the inhabitants of the state are matters of public concern. In furtherance of this purpose, it is the policy of the state to encourage the prompt and efficient provision of health and health-related services at a reasonable cost by the private and public sectors in modern, well-equipped health facilities accessible to the communities to be served. (http://unix2.nysed.gov/ils/ legislature /legis.html)