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Federal audit shows Yale's Medicare
billing practices in good health The Office of Inspector General of the U.S. Department of Health and Human Services (HHS) has given the School of Medicine a clean bill of health regarding its Medicare billing practices at Yale-New Haven Hospital. The School of Medicine was one of 49 institutions nationwide notified that they would be audited under the HHS Physicians at Teaching Hospitals (PATH) audit program. Under Medicare rules, teaching physicians are permitted to bill for care they directly provide to patients. In addition, if the care is provided by a resident, the teaching physician supervising the resident can bill for those services only if he or she is sufficiently involved in the care, and if that involvement is appropriately documented. How much involvement was sufficient and what kind of documentation was required were matters of debate and confusion until HHS adopted new regulations in 1996 that attempted to clarify these issues. The HHS PATH audit program has focused on Medicare payments to teaching physicians in academic medical centers for care provided before the new regulations were issued. Many academic medical centers have complained that the PATH audits are unfairly applying the new rules retroactively, finding innocent errors caused by confusion and unfairly calling them fraud. The audit at Yale began in August 1996, and auditors reviewed a sample of Medicare payments to Yale School of Medicine for patients seen by Yale faculty physicians in 1994. The HHS auditors' conclusion: Yale is in compliance. "The results of this audit show Yale's commitment to compliance," said Dean David A. Kessler, M.D. "Compliance is difficult at times because the rules and regulations are complex and sometimes unclear. For Yale to have come through this audit so well is a tribute to the doctors and administrators at the School of Medicine."  Urban health program broadens community outreach efforts The U.S. Department of Health and Human Services' Health Resources and Services Administration (HRSA) has awarded nearly half a million dollars to the Yale Urban Health Program over a three-year period. One of 16 Public Health Special Projects funded by HRSA this year, the Urban Health Program will use the grant to expand collaborations within the Yale medical center, the University and the greater New Haven area. The grant allows the program's leaders to expand curricula and create new programs, including student internships and a minority fellows program. Funds will also be used to sponsor the second annual Urban Health Lecture Series, which began in late October. Lecture topics include The Effects of Pesticides on Children, School Health, Prevention of HIV Among Drug Users in New Haven, and Prenatal Cocaine Exposure. According to Nora E. Groce, Ph.D., assistant professor of public health, the lecture series highlights some critical issues facing the urban community today, including violence prevention, homelessness and abuse. "The HRSA grant will help us get some of the most talented and motivated public health, medical and nursing students working together to improve the well-being of people in urban communities," says Dr. Groce, principal investigator for the grant and one of three co-directors of the Urban Health Program. The Urban Health Program, created in 1995 with a planning grant from the Pew Charitable Trusts, fosters interaction between students at Yale, faculty and the community. According to Dr. Groce, the program aims to bring more community practitioners into the University to share their experiences and expertise. Executive advisors include Michael H. Merson, M.D., dean for public health; Ralph I. Horwitz, M.D., chair of internal medicine; and Margaret Grey, Dr.P.H., associate dean for research and doctoral studies at the School of Nursing. The co-directors include Dr. Groce, Patrick G. O'Connor, M.D., M.P.H., associate professor, general medicine, and Martha Swartz, R.N., M.S., associate professor of nursing. The program's coordinating director is Wanda Anderson Harris, M.Ed., M.P.A. "We want the program to produce a generation of students who can leave Yale with invaluable experiences on the cutting edge of urban health challenges," says Wanda Harris. Study documents dumping of psychiatric patients Two-thirds of psychiatric hospitals providing inpatient mental health care in the United States are reported to dump patients for economic reasons, according to a Yale/Harvard study published in the journal Health Services Research. Patient dumping is the practice by which hospitals transfer unprofitable patients, specifically those without insurance coverage, to public hospitals and community mental health centers (CMHCs), which are required by law to care for these patients after private financial resources have been exhausted. This is the first national analysis of the factors that promote or constrain economically motivated transfers of patients in relation to competitive pressures, hospital ownership and managed care practices. "This form of patient dumping appears to be substantially exacerbated by increased competition among hospitals and reductions in the capacity of state-run psychiatric hospitals," Mark J. Schlesinger, Ph.D., associate professor of public health at Yale, and colleagues from Harvard University's Kennedy School of Government wrote in the journal's December issue. In addition to tax exemptions, the primary way hospitals subsidize care for patients without coverage is through profits made by treating insured patients. This practice has become increasingly difficult in recent years with the growth of managed care and other methods implemented to reduce the cost of health care delivery, such as the use of the prospective payment system for Medicare and other insurers, utilization review by insurance companies, and reduced public compensation pools. The researchers found that 25 percent of the survey respondents (directors of CMHCs) reported a great deal of dumping occurred in their service area, with slightly more than half of those patients transferred on economic grounds. Twenty-two percent of the CMHCs reported substantial adverse effects on their agencies due to dumping. Seventy-five percent reported that transfers based on economic grounds were more likely to occur from for-profit hospitals. Yale, SCIREX Corp. open unit for psychiatric drug research The Department of Psychiatry and SCIREX Corp. have announced a new collaboration to conduct clinical research on potential new drugs for psychiatric disorders. The SCIREX Clinical Research Unit at Yale, which opened Nov. 10 in a 6,000 square-foot facility at 320 Congress Ave., will conduct studies of central nervous system-focused drugs. "New treatments for psychiatric disorders are desperately needed, and the complexity of drug approval requirements is significant," says Michael Choukas, SCIREX'S president and chief executive officer. "By collaborating with full-time Yale faculty psychiatrists, we hope to speed clinical drug development and potentially reduce the time it takes for new therapeutic discoveries to reach the market." SCIREX, a contract research organization headquartered in Blue Bell, Pa., performs drug development services for pharmaceutical and biotechnology companies. The company will work closely with Yale psychiatry faculty members to plan and conduct central nervous system clinical studies. Faculty expertise centers on basic neuroscience, molecular neurobiology and genetics, neuropsychopharmacology and clinical biological psychiatry. Current research projects concentrate on depression, anxiety disorders including post-traumatic stress disorder, obsessive compulsive disorders, schizophrenia and substance abuse. "University medical schools have traditionally been the proving ground for some of the most revolutionary new advances in medical science. Yet over the past decade, health care management and dwindling government dollars have eroded the financial base needed to support this critical work," says Benjamin S. Bunney, M.D., chairman of the Department of Psychiatry and the Charles B.G. Murphy Professor of Psychiatry and Pharmacology. "By working together, we gain not only the freedom to search for new discoveries, but also earlier access to novel therapeutic compounds which could lead to increased understanding of both normal and diseased brain function," he said. "Ultimately, our patients will benefit because our combined efforts may result in decreasing the time it takes for new therapeutic discoveries to reach the market." Grant from insurer funds two outcomes research projects Insurance giant Aetna Inc. has awarded more than $750,000 to the School of Medicine to fund research aimed at improving health outcomes. The grants are among $6 million awarded to 13 institutions through the company's Quality Care Research Fund. The two grants are as follows:  $468,066 to the School of Medicine and Yale New Haven Health System in collaboration with Aetna subsidiary U.S. Quality Algorithms to compare managed care and fee-for-service insurance in the care and outcomes of elderly patients with heart attacks. This study will build on the Cooperative Cardiovascular Project (CCP), a national Medicare quality improvement project, to compare tests, procedures, specialty care, readmissions and mortality among those elderly heart attack patients treated under managed care and those treated under traditional fee-for-service. "Managed care is emerging as an important system of administering medical care to the elderly individuals, and this grant will allow us to evaluate how well it serves elderly patients after heart attacks," said Harlan M. Krumholz, M.D., who will lead the study. Dr. Krumholz is associate professor of medicine (cardiology) and director of the Center for Outcomes Research at Yale-New Haven Hospital. $300,000 to the School of Medicine to study the effectiveness of Bright
Beginnings. This volunteer-based mentoring program that encourages vulnerable, young
mothers to develop healthy lifestyles for themselves and their children and to make
good use of illness prevention resources. The study will examine the effectiveness
of this broad-based, parent support program by evaluating such measures as completion
of well-baby check-ups, inappropriate use of the emergency department, the number
of preventable injuries and each mother's sense of parenting competency."We believe that Bright Beginnings could serve as a model to help alleviate some of the substantial health problems faced by underserved, inner-city children and their families," said John M. Leventhal, M.D., HS '76, professor of pediatrics and medical director of the program, which has served 115 families in greater New Haven during the past three years. Added Elizabeth Demir, chair of the Bright Beginnings advisory committee: "This Aetna grant will allow us to expand the number of successful matches between mothers and mentors this promising program can sustain each year and, if study results substantiate our early findings, we should be able to attract continued funding." The program was launched in 1995 by the Friends of the Children's Hospital, a volunteer organization affiliated with the Department of Pediatrics. Psychiatric hospitals may be deluged with sex offenders When convicted sex offenders finish serving prison time, many of them will go directly from a jail cell to a psychiatric ward. A June 1997 U.S. Supreme Court ruling says that prisoners who fit the profile of "sexually violent predators" will immediately be committed to hospitals for psychiatric care. At an estimated annual cost of between $60,000 to $130,000 per patient, this will drain a psychiatric system that is already strapped for funds, says Howard V. Zonana, M.D., professor of psychiatry at the medical school and clinical lecturer at Yale Law School. "Society certainly has a right to be protected from sexual violence," says Dr. Zonana, who chairs the American Psychiatric Association's Task Force on Sexually Dangerous Offenders. "But I am also concerned with the enormous cost and the impact on the quality of care this ruling will have on patients with severe incapacitating mental illnesses whose ability to survive in the community requires extensive resources." According to Dr. Zonana, whose views were expressed in the Nov. 14 issue of the journal Science, treatment for sex offenders requires maximum-security facilities that are not usually found in hospital settings. "If sex offenders are unable to control their behavior, they should be given longer prison terms and those who need psychiatric treatment should have it available before the end of their criminal sentences," says Dr. Zonana. The U.S. Supreme Court ruling found that "sexually violent predators" can be hospitalized after and only after they have served their entire criminal sentence. Dr. Zonana maintains that these statutes provide a very low threshold for people to be determined mentally ill. The court's decision makes it possible for sex offenders to be hospitalized based on remote past behavior and any mental abnormality or personality disorder that makes them likely to repeat their behavior. According to Dr. Zonana, this issue raises tough questions such as what mental illnesses or conditions are sufficient to meet the sexually violent predator requirement. "This law is so broadly drawn that rapists who display anti-social behavior or traits could be hospitalized," says Dr. Zonana. "This is transforming criminal behavior into mental illness, further stigmatizing the mentally ill and serving a primary function of preventive detention." EPH, Hospice Institute work to improve access to care The John D. Thompson Hospice Institute in Branford, Conn., and experts from Yale's Department of Epidemiology and Public Health have launched a three-year educational program to improve access to palliative care for the terminally ill. "Our partnership with Yale will provide a much-needed educational effort about hospice and palliative care," says Rosemary Johnson-Hurzeler, R.N., M.P.H. '75, the institute's president and chief executive officer. "The care provided, as well as the related educational and research programs, will focus on life, not death," she adds. According to Elizabeth H. Bradley, Ph.D., assistant professor of public health at Yale, the project is offering a formal education program to physicians, nurses and other health care providers at acute-care hospitals in Connecticut. "We will measure the impact of the educational program on medical professionals' knowledge and attitudes about hospice, as well as utilization of hospice services," says Dr. Bradley, research director for the hospice project. The educational program was designed by the John D. Thompson Hospice Institute for Education, Training and Research Inc. (named for a late Yale EPH faculty member) and its affiliate, the Connecticut Hospice, the nation's first hospice program. In future years, the two groups anticipate making this educational program available to all hospitals in Connecticut. Study explores connections between menopause and mood The number of women experiencing menopause is expected to triple over the next decade, causing an increased demand for more effective treatment of symptoms such as mood changes. To address this situation, Angela Cappiello, M.D., Ph.D., chief of the Menopause Mood Disorders Clinic and co-director of the Behavioral Gynecology Program at the School of Medicine, has launched a series of studies on mood disorders in menopausal women that may offer relief for some symptoms of menopause. "My goal is to understand the connection between the brain and the female hormone estrogen," says Dr. Cappiello, whose study is funded by the Lilly Center for Women's Health. "Female hormones may protect women from stress. Loss of estrogen could cause women to be more vulnerable to stressful life changes that usually occur around the time of menopause, including changes in employment, marriage, and children leaving home." Dr. Cappiello is studying how healthy menopausal women respond to a serotonin depletion induced by a low tryptophan diet. She expects that menopausal women treated with estrogen will have a more stable mood and will be less sensitive to the mood changes of a low tryptophan diet. In addition, Dr. Cappiello is also testing whether the most effective treatment for depressed menopausal women is estrogen alone, fluoxetine (Prozac) alone, or the combination of both fluoxetine and estrogen. "If we can prove that estrogen regulates serotonin function, then that will be a big finding," says Dr. Cappiello. An estimated 30 million women are expected to reach menopause in the next 10 years, and more than one-third of a woman's life is post-menopausal, according to Dr. Cappiello. Previous research has shown that estrogen regulates brain activity and that loss of estrogen can affect mood and behavior. Approximately 85 percent of women have some kind of reaction to estrogen loss, such as mood changes, depression, hot flashes and insomnia. Fifteen percent of menopausal women suffer from more severe symptoms. "We want women to know that treatment is available," says Dr. Cappiello who will use her study to inform women that they do not have to suffer in silence. "Research on menopause is relatively new. It is getting more attention because more and more women are becoming menopausal and there is greater interest in women's health issues." The Menopause Mood Disorders Clinic is part of the Yale Behavioral Gynecology Program operated jointly by the departments of Psychiatry and of Obstetrics and Gynecology at the School of Medicine. Contributors: Helaine Patterson, Karen Peart, Michael Fitzsousa, Judith Winslow, Cynthia Atwood, Ilene Shub Lefland, Susan Alksnis and Carolyn Battista. < back | top of page | next >  Originally published in Yale Medicine, Winter/Spring 1998. Copyright © 1998 Yale University School of Medicine. All rights reserved. |
