As nurse practitioners lobby to expand their authority and scope of practice in many states, a New England Journal of Medicine study released Wednesday documents a deep chasm between how doctors and nurses regard the issue.

The study found the two groups overwhelmingly agreed that nurse practitioners should be able to practice to the full extent of their schooling and training. But doctors were less likely to concur that advanced practice nurses should lead medical homes, which deliver team-based, coordinated care to patients. Only 17 percent of the 505 primary care physicians  surveyed agreed with that notion, compared to 82 percent of the 467 nurse practitioners surveyed.

The two groups also disagreed about whether nurse practitioners should be paid equally for providing the same health services. More than 64 percent of nurse practitioners agreed with the idea of equal pay, as opposed to less than 4 percent of doctors.

The debate over the role of nurse practitioners has intensified as a result of concerns over a shortage of doctors as an estimated 25 million people gain insurance under the health care law.  Nurse practitioners argue they can fill some of those needs if they are granted greater scope of practice.

That debate is reflected in the study’s finding about the groups’ conflicting views about the quality of care provided by doctors versus nurse practitioners. When researchers asked whether they felt the quality of care provided by physicians in exams and consultations was higher than that provided by nurse practitioners, more than 66 percent of doctors agreed, while 75 percent of nurses disagreed.

“We’ve done a lot of comparative surveys with health professionals but we’ve just never found gaps this big,” said Dr. Karen Donelan, an assistant professor of medicine at the Harvard School of Medicine and the study’s lead author. “When we get on the ground and we survey the people actually doing the work and working together, we see some of those professionals come closer together. We didn’t observe that here.”

Donelan pointed out that most nurse practitioners in the study — approximately 75 percent — said they are already practicing to the full extent of their training. Survey respondents who did not have this opportunity blamed their limited practice on state restrictions, hospital regulations and work setting.

During an interview, Donelan also said she was surprised by the level of disagreement in regards to the quality of care, since previous research findings have suggested little variation in the work done by  nurse practitioners and primary care doctors.

During a February 2013 interview, David Hebert, the CEO of the American Association of Nurse Practitioners, described the safety concerns raised by physicians as a “total red herring,” and added that “nurse practitioners have been practicing safely and providing great outcomes for decades.”

In March, the president-elect of the American Academy of Family Physicians, Reid Blackwelder, emphasized his support for a more collaborative approach between the two clinician groups, noting their roles are not interchangeable.

Differences aside, Donelan’s study shows that the majority of practitioners in both groups agreed that increasing the number of nurse practitioners would improve timeliness of care. However, less than a third of doctors said such an increase would boost safety or effectiveness of care.

Nurse practitioners, on the other hand, overwhelmingly felt such an increase would improve care. Close to 81 percent, for example, thought the growth would improve access to health care for the uninsured and 77 percent said it would result in lower health care costs.

“As a team, this kind of inter-professional disagreement is not a good thing when we’re trying to achieve better teamwork,” Donelan said. “The conflict over roles has got to be worked out so that it’s clear for patients when they get their care.”

Moving forward, she said she hopes that both doctors and nurse practitioners will acknowledge their differences and bridge the gaps that keep them from working together.

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Dr. Thomas Bellavia transformed his traditional medical practice in Hasbrouck Heights, N.J., into a so-called medical home where patients are seen by teams of doctors and nurses.  He says it has paid off in better, more coordinated care for his patients and healthier income for the nurse practitioners and physicians in his group.

As state governments get ready for the Affordable Care Act coverage expansion, some are taking a close look at their networks of health care professionals to make sure they will be able to meet increased demands as more people gain health insurance. California is one of 15 states expected to consider legislation this year that would give advanced practice nurses more independence and authority.

Tina Clark is a nurse practitioner at Glide Health Services, a clinic in San Francisco’s Tenderloin district, a low-income section of the city. Glide is run by nurses with advanced training. A physician visits the clinic 12 hours a week, to sign forms and consult on difficult cases. Even under current law, Clark can see patients without a doctor in the room.

Anastacia Casperson, who has struggled with homelessness and drug addiction, came to the clinic because she was alarmed about swelling in her legs. Clark spends a half hour with Casperson, gives her a prescription for a diuretic and talks to her about quitting smoking. Casperson says she’s been coming to this clinic for a few years.

“They have compassion for a client. They have understanding for a client,” Casperson says. “I like the nurses here because they’re like one big family, and they all work together.”

Right now, California law says nurses must follow procedures set after consulting a doctor. But lawmakers are considering eliminating that requirement. And that idea doesn’t sit well with some doctors.

“Nurses and nurse practitioners are a very, very important part of the health care team, but they are part of a team,” says Dr. Paul Phinney, President of the California Medical Association.

Phinney’s group is opposed to allowing more independence for nurses. He says they don’t have as much training and may not know as much about testing and technology as doctors.

Plus, he says, there’s nothing in the bill that would require the empowered nurses to go where they are needed most.

“I would be very surprised if — should this bill pass — that all of a sudden, you’ll see a massive egress of nurse practitioners out into medically-underserved areas. I just don’t see that happening,” he says.

But University of California San Francisco health care economist Joanne Spetz says research shows otherwise.

“Nurse practitioners are more likely to practice in settings that serve large shares of Medicaid patients, and they’re somewhat more likely to practice in rural communities,” Spetz says.

Nurse practitioners can be trained much more quickly than a physician, and their compensation is lower, Spetz points out.

“So when a legislature is looking at the insurance of hundreds of thousands of people and the demand for care that those people are going to have, getting health professionals to meet their needs as quickly as possible and as cost-effectively as possible is a real need,” Spetz says.

The next step for the California bill on nurses is a hearing in the state Senate Appropriations committee on Monday.

This story is part of a partnership that includes Capital Public Radio, NPR and Kaiser Heath News.

Photo of Nurse Practitioner Valerie Mumaw, patient Benjamin Cuatle and his wife Valerie Tlacuatl courtesy USDA

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Four states that have snubbed the federal health law by defaulting to the federal government to build new online insurance marketplaces and not agreeing to expand Medicaid are getting new jobs at call centers that will help consumers understand their new coverage options this fall.

Up to 9,000 jobs are expected to be created at call centers to support the new federally run marketplaces. A Department of Health and Human Services spokeswoman said some of them will be added to existing Medicare call centers in Phoenix, Chester, Va., Lawrence, Kan., and Tampa, Fla.– all states with Republican leaders who oppose the  law.

A fifth center in Coralville, Iowa and a sixth in Corbin, Ky., will also be expanded, she said. Plans are still being finalized for other locations, she said.

Of those states, only Kentucky is setting up its own online insurance marketplace that will help people shop for individual or small employer coverage. Iowa, will run its exchange in partnership with the federal government.  The other states are relying entirely on the federal government.

Of the six states getting call centers, only Kentucky has committed to expanding Medicaid in 2014, even though governors in Florida and Arizona say they support it. So far, 22 states have agreed to expand Medicaid.

The jobs are through Vangent, a General Dynamics Information Technology subsidiary, which was awarded a $530 million one-year contract  by the federal government to set up call centers to answer inquiries related to the insurance marketplaces in 34 states where they will be run in whole or part by the federal government. The government estimates that next October, when the marketplaces go live, the call centers will be open seven days of the week, 24 hours a day, handling 6.1 million phone calls and 23,000 e-mails. The contract could be renewed for up to nine more years, making it potentially worth more than $5 billion.

States running their own marketplaces will have their own call centers.

The marketplaces are expected to expand health coverage to about 27 million people by 2016. Under the federal contract awarded to Fairfax, Va.-based Vangent, the company will also field inquiries about Medicare, Medicare Advantage and “other relevant programs,” the award announcement stated.

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This Kaiser Health News story produced in collaboration with The Washington Post

Until it happened to him, Itzhak Brook, a pediatric infectious disease specialist at Georgetown University School of Medicine, didn’t think much about the problem of misdiagnosis.

That was before doctors at a Maryland hospital repeatedly told Brook his throat pain was the result of acid reflux, not cancer. The correct diagnosis was made by an astute resident who found the tumor  —  the size of a peach pit  —  using a simple procedure that the experienced head and neck surgeons who regularly examined Brook never tried. Because the cancer had grown undetected for seven months, Brook was forced to undergo surgery to remove his voice box, a procedure that has left him speaking in a whisper. He believes that might not have been necessary had the cancer been found earlier.

“I consider myself lucky to be alive,” said Brook, now 72, of the 2006 ordeal, which he described at a recent international conference on diagnostic mistakes held in Baltimore. A physician for 40 years, Brook said he was “really shocked” by his misdiagnosis.

See Also: How to protect yourself from medical errors

But patient safety experts say Brook’s experience is far from rare. Diagnoses that are missed, incorrect or delayed are believed to affect 10 to 20 percent of cases, far exceeding drug errors and surgery on the wrong patient or body part, both of which have received considerably more attention.

Recent studies underscore the extent and potential impact of such errors. A 2009 report funded by the federal Agency for Healthcare Research and Quality found that 28 percent of 583 diagnostic mistakes reported anonymously by doctors were life-threatening or had resulted in death or permanent disability. A meta-analysis published last year in the journal BMJ Quality & Safety found that fatal diagnostic errors in U.S. intensive care units appear to equal the 40,500 deaths that result each year from breast cancer. And a new study of 190 errors at a VA hospital system in Texas found that many errors involved common diseases such as pneumonia and urinary tract infections; 87 percent had the potential for “considerable to severe harm” including “inevitable death.”

Misdiagnosis “happens all the time,” said David Newman-Toker, who studies diagnostic errors and helped organize the recent international conference. “This is an enormous problem, the hidden part of the iceberg of medical errors that dwarfs” other kinds of mistakes, said Newman-Toker, an associate professor of neurology and otolaryngology at the Johns Hopkins School of Medicine. Studies repeatedly have found that diagnostic errors, which are more common in primary-care settings, typically result from flawed ways of thinking, sometimes coupled with negligence, and not because a disease is rare or exotic.

The problem is not new: In 1991, the Harvard Medical Practice Study found that misdiagnosis accounted for 14 percent of adverse events and that 75 percent of these errors involved negligence, such as a failure by doctors to follow up on test results.

Related: ICU Patients Twice as Likely to Suffer Fatal Misdiagnosis

Despite their prevalence and impact, such mistakes have been largely ignored, Newman-Toker and others say. They were mentioned only twice in the Institute of Medicine’s landmark 1999 report on medical errors, an omission some patient safety experts attribute to difficulties measuring such mistakes, the lack of obvious solutions and generalized resistance to addressing the problem.

“You need data to start doing anything,” said internist Mark L. Graber, founding president of the Society to Improve Diagnosis in Medicine and a leading errors researcher. Despite dozens of quality measures, Graber said, he is unaware of “a single hospital in this country trying to count diagnostic errors.”

In the past few years, a confluence of factors has elevated the long-overlooked issue. In his 2007 bestseller, “How Doctors Think,” Boston hematologist-oncologist Jerome Groopman vividly deconstructed the flawed thought processes that underlie many diagnostic errors, including several he made during his long career.

More recently, an influential cadre of medical leaders has been pushing for greater attention to the problem. They cite concerns about the growing complexity of medicine and increasing fragmentation of the health-care system, as well as relentless time pressures squeezing doctors and the overuse of expensive, high-tech tests that have supplanted traditional hands-on skills of physical diagnosis.

Publicity about the death last year of 12-year-old Rory Staunton, sent home from an emergency room in New York after doctors missed the raging systemic infection that quickly killed him, have put a human face on the problem. At the same time, new digital databases such as IBM’s Watson and Isabel promise to boost doctors’ accuracy, although their usefulness remains a matter of debate.

“One of the reasons it’s time to begin looking at it is that so many of the quality measures we use now assume that the diagnosis is the right one in the first place,” said Christine Cassel. A member of the panel that wrote the 1999 IOM report, she is now president and chief executive officer of the American Board of Internal Medicine.

But what if it’s not?

In a much-cited essay, Robert Wachter, associate chair of the Department of Medicine at the University of California at San Francisco, wrote that a hospital could earn “performance incentives for giving all of its patients diagnosed with heart failure, pneumonia and heart attack the correct, evidence-based and prompt care — even if every one of the diagnoses was wrong.”

Discovered Late — Or Never

Unlike drug errors and wrong-site surgery — mistakes that patient safety experts consider to be “low-hanging fruit” amenable to solutions such as color-coded labels and preoperative timeouts by the surgical team — there is no easy or obvious fix for diagnostic errors. Many are complex and multifaceted, and may not be discovered for years if ever, said Graber, a senior fellow at RTI International, a research firm based in Research Triangle Park, N.C.

“There is probably nothing more cognitively complicated” than a diagnosis, he said, “and the fact that we get it right as often as we do is amazing.”

But doctors often don’t know when they’ve gotten it wrong. Some patients affected by misdiagnosis simply find a new doctor. Unless the mistake results in a lawsuit, the original physician is unlikely to learn that he blew it — particularly if the discovery is delayed. While diagnostic errors are a leading cause of malpractice litigation, the vast majority do not result in legal action.

Some environments are more susceptible to error than others. Graber calls the emergency room “a petri dish” for diagnostic mistakes: The doctor doesn’t know the patient, the patient doesn’t trust the doctor, and time pressures and frequent interruptions are the rule.

Misdiagnosis is not limited to hospitals; a recent commentary on the Texas VA study by Newman-Toker and Martin Makary estimates that “with more than half a billion primary care visits annually in the United States . . . at least 500,000 missed diagnostic opportunities occur each year at U.S. primary care visits, most resulting in considerable harm.”

There is another reason such mistakes have been long ignored: They are regarded as an unusually personal failure in a profession where diagnostic acumen is considered the gold standard.

“This really gets to who we are as clinicians,” said internist Robert Trowbridge, who directs the medicine clerkship program for Tufts University medical students at Maine Medical Center in Portland.

“Overconfidence in our abilities is a major part of the problem,” said Graber, who believes doctors have gotten a pass for too long when it comes to diagnostic accuracy. “Physicians don’t know how error-prone they are.”

Many, he noted, wrongly believe that the problem is “the other guy” and that they don’t make mistakes. A 2011 survey (pdf) of more than 6,000 physicians found that 96 percent felt that diagnostic errors are preventable; nearly half said they encountered them at least once a month.

In the Texas VA study, more than 80 percent of cases lacked a differential diagnosis, in which a doctor not only declares what he believes is ailing the patient but also lists other potential causes of the problem based on symptoms, test results and a physical exam.

“A differential helps people to cognitively focus,” said Hardeep Singh, director of the Houston VA Patient Safety Center of Inquiry. Failure to ask “What else could this be?” can cause premature fixation on the incorrect diagnosis, said Singh, the study’s lead author.

At Maine Medical Center, Trowbridge spearheaded a pilot program launched in 2010 to persuade doctors to anonymously report diagnostic errors, which would then undergo comprehensive analysis. He said he had to “hound” his colleagues to report mistakes. During the first six months, 36 errors that would otherwise have gone unreported were identified; most were deemed to have caused moderate to severe harm.

Trowbridge said the program has changed how he practices. “I’m much more reflective, much more attuned to the errors I’m prone to make. I work with checklists more.”

It Wasn’t Fibromyalgia

While second opinions are one strategy believed to reduce misdiagnosis, the original error may be the basis of a cascade of mistakes.

For nearly three years, beginning in February 2008, financial executive Karen Holliman logged more than 50 visits with various doctors in Durham, N.C., trying to get help for the increasingly severe fatigue that had plagued her for several years as well as back pain so excruciating that she wound up in a wheelchair.

Doctors variously told her she had fibromyalgia, chronic fatigue syndrome or a psychiatric problem. The real reason for her symptoms was metastatic breast cancer, which had riddled her spine, fracturing her back. Signs of cancer had been found on an MRI scan performed in February 2008. But a bone scan performed a few weeks later did not indicate cancer; her internist told her she did not have cancer, and doctors repeatedly failed to investigate the discrepancy.

To make matters worse, Holliman was taking hormone replacement pills prescribed by her internist to combat hot flashes; the drug fed her breast cancer.

“I’m terminal,” she said. In December 2010, when she was told she had Stage IV breast cancer, an oncologist estimated her life expectancy at about three years. “I could have been diagnosed in 2008,” she said, adding that she believes timely diagnosis and treatment might have extended her life expectancy to 10 years.

Holliman has regrets: that she never got a second opinion from an internist or orthopedist, that she didn’t question the radiologists who performed her scans and that she failed to obtain her medical records earlier.

During meetings last year attended by her family, including a relative who is a prominent physician, as well as by her doctors and the hospital system for which they worked, Holliman said, a hospital lawyer called her case “a series of unfortunate events” but denied that the hospital was liable for the delayed diagnosis.

“I spent a lot of time being angry,” said Holliman, who is 52. She said she has not filed a malpractice suit because she was advised she was unlikely to win. “Now I’m just trying to live a really great life in the time I have left.”

Photo by benchilada via Flickr

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This Kaiser Health News story produced in collaboration with USA Today

After Lois Frarie, a 93-year-old retired teacher from Monterey, Calif., spent four days at a local hospital while being treated for a broken elbow and pelvis, she went to a nearby nursing home to build up her strength.

But her family was stunned to find out that they would have to pay thousands of dollars up front since two of the days she spent in the hospital were considered “observation care.” She wasn’t an admitted patient for at least three consecutive days and therefore she didn’t qualify under federal law for Medicare’s nursing home coverage.

“I assumed I was under the hospital’s care,” said Frarie.

Advocates for seniors say the distinction is not fair to patients. They are taking their argument to federal court in Hartford, Conn., Friday for the first hearing on a lawsuit seeking to have Medicare eliminate the observation label. Government lawyers argue in court filings that Medicare considers observation care an outpatient service and if elderly patients think they should have been admitted to the hospital, they should file an appeal.

Yet federal records and interviews with patients and advocates across the country show that many observation patients who call Medicare about the billing problem find out there is nothing that Medicare can do to help — as Frarie’s and other persistent families have learned first-hand.

“People are often told there is nothing to appeal,” said Judith Stein, executive director of the Center for Medicare Advocacy, which is representing 14 seniors in the lawsuit.

See also: Medicare Inpatient vs. Outpatient? Not being formally admitted can cost you thousands

Last week, Medicare sought to help observation patients who have lost nursing home coverage and who also pay higher hospital costs than admitted patients. The agency proposed changes to the hospital payment system that would require, with some exceptions, patients who stay in the hospital two days or less to be classified as observation patients, and those who stay longer would have to be admitted.

However, the proposal has been criticized by patient advocates, the American Hospital Association and the American Medical Association because it would keep the three-inpatient-day requirement for nursing home coverage.

Frarie’s nursing home bill for nearly three months of care came to $19,000. Her family took the first step in the appeals process, asking Medicare to count all four days in the hospital as inpatient so that she would have the minimum required for Medicare coverage for her nursing home stay.

Then they hit a dead-end.

A Medicare appeals coordinator, writing to Frarie’s niece Sherry Smith in February, said the agency could not accept the appeal because “the claim(s) or date(s) of service identified in your request have not been denied.” In other words, Frarie received and Medicare paid for the care the hospital determined she needed, including her two days as an observation patient.

The letter didn’t say how to challenge this determination, information that is required whenever an appeal is denied.

The government’s lawyers say the plaintiffs must go through the appeal process – all five levels if necessary – before they can file a lawsuit.

“Indeed, to challenge coverage and payment determinations, the Medicare statute and regulations afford program beneficiaries extensive opportunities for review, including several levels of administrative review, and, potentially, judicial review,” government lawyers write in papers asking a federal judge to dismiss the suit.

But hospitals are not required to tell patients they are under observation, Medicare officials have said. Another obstacle for seniors is that the three-day requirement is part of federal law.

Once patients leave the hospital and then find out they were receiving observation services – when a bill arrives – it’s too late: hospitals and physicians are prohibited from reclassifying observation patients as inpatients once they’ve been discharged, according to Medicare rules.

If the federal judge won’t eliminate observation care, the seniors’ lawyers are asking that hospitals be required to tell patients when they are in observation and allow them to appeal that decision before they leave.

A Medicare spokeswoman declined to answer questions about appealing observation care because it is agency policy not to comment on pending litigation.

The number of Medicare patients receiving observation care jumped 69 percent in only five years, to 1.6 million in 2011, according to the most recent federal data. Even though Medicare recommends that hospitals decide within 24 to 48 hours whether to admit a patient, observation stays exceeding 24 hours have nearly doubled to 744,748.

Few of those patients turn to the appeals process for help. Medicare officials would not disclose how many beneficiaries file observation care appeals. But buried in a document the agency submitted to Congress last month explaining its proposed budget request is a revealing figure: out of 3.2 million appeals received last year, seniors filed less than 10 percent. The rest come from hospitals, doctors, nursing homes and other providers.

When seniors call Medicare to complain about observation status, the option to appeal is rarely mentioned. According to records of 316 complaints — the total Medicare said it received from beneficiaries or their representatives about observation since 2008 — a typical response was that Medicare “cannot intercede with hospital/physician regarding change of status.” In a response to one of dozens of congressional inquiries, officials “advised senators [Center for Medicare and Medicaid Services] cannot change a hospital stay classification.”

In addition, information provided by officials about the scripts used by the 800-MEDICARE call centers to answer observation care questions also do not mention that callers can appeal the denial of nursing home coverage or their extra hospital charges, including non-covered drugs.

“I called everyone and their grandmother,” said Arlene Roach in Lynn, Mass., who is trying to appeal her mother-in-law’s $33,000 nursing home bill after she spent three nights in the hospital for observation.

“Medicare shows that no payment can be made because the services on the claim do not reflect a 3 day qualifying stay for inpatient services,” wrote a Medicare contractor in Birmingham, Ala., last November in response to the first of two requests for coverage. This letter said nothing about appeals. But the denial of the second request included information on how to continue the appeal.

“It’s like hitting my head against the wall,” Roach said.

She was eventually referred to Diane Paulson, senior attorney at Greater Boston Legal Services, who is trying to get Roach a definitive decision from Medicare.

“This is a basic denial of due process,” said Paulson. “People are entitled to a written, timely decision and notice of the right to appeal.”

This article was produced by Kaiser Health News with support from The SCAN Foundation.

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 Photo by Ulrich Joho via Flickr

This KHN story was produced in collaboration with The Washington Post

Wanted: an advocate for a hospital patient. Long hours, no pay. Must be articulate, assertive, able to ask tough questions and stay cool under pressure. Blood relative or close friend preferred. Knowledge about the health-care system a plus.

“It would be ideal to have Dr. Marcus Welby looking in on you and coordinating everything, and giving you a big reassuring smile but that’s not the reality right now,” said Karen Curtiss, who wrote a handbook about managing the care of a hospitalized relative, based on her own experiences (“Safe & Sound in the Hospital” available through PartnerHealth.com).

Related: A patient checklist for your hospital stay

Curtiss points out that the patient has a right to know the name and position of the physician who is overseeing their hospital care. All care providers should introduce themselves when they come into the room; if they don’t, remind them.

Patients also have a right to review their medical records at the bedside and to receive information about the benefits and risks of any procedure or treatment they are offered. If the patient is mentally competent, he or she can give an advocate permission to see the records; it can be done verbally, and the advocate’s name can be put in the medical chart.

Get in on the discussion: Advice Needed on Medical Alert Products (AARP Online Community)

To help advocates, the patient safety organization PULSE has drawn up a checklist that uses the acronym FILMS, which stands for “falls,” “infections,” “literacy,” “medication” and “surgery”:

• Falls. Make sure the staff are aware when a patient is at risk of falling, and have the patient evaluated if you are concerned. Falls are a leading cause of hospital injuries.
• Infections. Don’t be shy about asking health care providers if they have washed their hands or asking them to do it again in front of you.
• Literacy. Read any forms the patient is asked to sign. (He or she may be unable to absorb the information completely.)
• Medication. Doctors and hospital staff members should always explain to the patient which drugs they are being given. Ideally, medication should be in the original wrapper. Medication errors injure 1.5 million people each year.
• Surgery. Before an operation, make sure the site of surgery is marked and verified by the doctor. The advocate can and probably should be present when this is done. There are still 40 cases every week of surgeries done on the wrong body part. If the patient has not been given antibiotics, ask if there is a reason; taking antibiotics preventively before surgery has been shown to reduce infection risk. Also, make sure the patient has a warm blanket before and after surgery, since staying warm also reduces infection risk.

It’s a good idea to go to the hospital with a notebook and pens, and a file of information including the patient’s insurance, names of doctors, contact information for key family members and friends, and lists of the patient’s allergies, past procedures and surgeries, medications, vitamins, supplements or herbs, and any special dietary needs.

Take antibacterial wipes to wipe down bedrails, the TV remote, phone and doorknobs, says Pulse’s Ilene Corina.

If the advocate feels the patient is in danger and they are not being heard, he or she should approach the nurse’s station and say they are calling a “Condition Help” and need a rapid response team. The phrases “Condition Help” and “rapid response team” are red flags to the hospital staff that the situation is grave, and the words should not be used lightly. “‘Condition Help’ is like calling 911 in the hospital,” Curtiss said. “Ask yourself: ‘If we were not in the hospital, would I call 911?’”

Last but not least, trust your gut: If you think something is wrong, get help.

Photo: Getty Images

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For the first time, the government will make information about financial relationships between doctors, teaching hospitals and drug manufacturers publicly available.

To comply with a provision in the Affordable Care Act, drug and device manufacturers, along with group purchasing organizations, will have to disclose all of their payments and other compensation to physicians and teaching hospitals. Those who don’t comply could be fined.

The information will be gathered beginning in August and disclosed by Sept. 30, 2014 on a new website of the Centers for Medicare & Medicaid Services. The site is part of the National Physician Payment Transparency Program, an effort to bring the financial relationships to light.

The possible conflict of interest that occurs when physicians receive gifts and incentives from drug companies has made news for the past few years. Dr. Charles Nemeroff, former Department of Psychiatry chairman at Emory University, earned $2.8 million by speaking and consulting for drug companies over seven years. An article in the Economist in March said drug companies spent more than $24 billion marketing to doctors in 2012.

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There was also a surge of coverage after the nonprofit media organization ProPublica produced a database called Dollars for Docs in October 2010, where people could look up physicians and payments they received from drug companies. “They have a right to know this information and ask questions about it if they want to,” said Charles Ornstein, a reporter at ProPublica who was part of the project.

He said the service attracted more than 5 million page views, and sparked discussion among physicians, lawmakers and consumers. Ornstein attributed the popularity of Dollars for Docs to the ability of consumers to look up their own doctors.

But publicly reporting these financial relationships may not be a complete solution, said Donald Light, a fellow at Harvard University’s Edmond J. Safra Center for Ethics.

Light, who researches institutional corruption in the development of prescription drugs, said a website like the new CMS database wouldn’t put a stop to the problem. He said ending pharmaceutical and device payments to doctors altogether would be more effective, giving the example of Kaiser Permanente, which doesn’t allow the physicians it employs to receive free drug samples or gifts. (KHN is not affiliated with Kaiser Permanente.)

“If we agree that the goal of medicine is to help patients become healthier, then these payments corrupt our goal,” Light said.

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By Jenny Gold, Kaiser Health News Staff Writer

One recent morning, 86-year-old Evelyne Lois Such was sitting at her kitchen table in Denver when the phone rang.  She didn’t recognize the phone number or the deep voice on the other end of the line. “He asked if I was a senior, and I said yes, and he said we are sending out all new Medicare cards and I want to make sure I have all of your statistics correct,” Such recounts.

“I kind of thought it was funny at first, and then I thought, you know, how dare they?” says Such. “There are some seniors who aren’t well and don’t think as well as they used to, and it just made me angry that they would be victimized like this.”

Law enforcement agencies are reporting an increase in these sorts of health insurance scams across the country. Many of the fraudsters seem to be preying on the public’s confusion over the massive changes taking place in the nation’s health care system.

Seniors are often targets — they’re more likely to be home to answer the phone, and they tend to have retirement savings that scammers hope to tap.  But they aren’t the only victims: The federal government received nearly 83,000 complaints of “imposter scams” last year—up 12 percent from the year before.

“America’s rife with health scams,” says James Quiggle, communications director at the Coalition Against Insurance Fraud in Washington, D.C. “Crooks are offering fake health coverage, stripped down policies masquerading as real coverage. They’re also selling … fake Obamacare coverage,” he explains.

Recent polls have found that well over half of Americans say they still don’t understand how the new health law will affect them.  “Crooks are playing on that confusion. Confusion is a crook’s best friend,” says Quiggle.

Related: Don’t Get Scammed by Phony IRS Agents

“Fraudsters are as attuned to what’s going on in the news as anybody else,” says Lois Greisman, who runs the division of marketing practices at the Federal Trade Commission. “Before Katrina hit land, websites were up soliciting funds to help victims of Katrina. This is not a surprise; this is par for the course.” A program as vast as the health care overhaul makes for a dangerous twist on the regular scams, she adds.

Greisman and her team are working to take down the scams as quickly as possible, but there is an endless number; scammers range from just your average amateur looking to make a quick buck, to well-organized crime rings that mass-produce fraud.

“The first line of defense is don’t take a call from out of the blue from anyone who’s offering to help you navigate the new health care market,” cautions Greisman. “Those kinds of cold calls just shouldn’t take place, same thing with an unsolicited email, an unsolicited text.”

Many people see through those sorts of simple scams, says Sally Hurme, an elder law attorney at AARP.  “But even if one in a thousand falls for the scam and gives up info or agrees to send information off to who knows where, they’ve made [the scammer’s] day. That’s what their job is,” says Hurme.  As the Affordable Care Act ramps up, the country is likely to see more frequent insurance scams, and they’re likely to get more sophisticated, she adds.

Savvy senior Evelyne Lois Such offers this advice for others who get a suspicious call: “Don’t answer too quickly. Think about the answer you give them and what they’re asking.” And never give up and personal or financial information over the phone.

Better yet? Just hang up.

Listen to the story at NPR’s Morning Edition

This article was produced by Kaiser Health News with support from The SCAN Foundation.

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• Join AARP: Savings, resources and news for your well-being

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President Barack Obama’s fiscal 2014 budget includes a variety of what he says are “manageable” changes for Medicare’s 54 million beneficiaries as well as for the hospitals, nursing homes and other health care providers that serve them.

That assessment has drawn concern from some patient and provider groups that, although recognizing the need to address the nation’s rising health care costs, say seniors shouldn’t bear the brunt of efforts to reduce entitlement spending.

“Instead of making harmful cuts to Medicare or shifting additional costs onto beneficiaries, we need to look for savings throughout the health care system, including Medicare,” said AARP Executive Vice President Nancy A. LeaMond.

What follows is a closer look at key provisions in Obama’s fiscal 2014 budget, which would reduce the growth in Medicare spending by $371 billion over the next decade. Keep in mind that Obama’s plan is far from the last word. House Republicans have approved their own fiscal 2014 blueprint, as have Senate Democrats.

1. Higher Cost Sharing for New Medicare Beneficiaries

• In 2017, 2019 and 2021, new Medicare beneficiaries would have to pay an additional $25 for their Part B deductible, for a three-year total of $75 to be added on to the cost of the Part B premium, which in 2013 is $147.

The administration says the change would “strengthen program financing and encourage beneficiaries to seek high-value health care services.” Seniors advocates say it’s an additional cost to people already struggling on fixed incomes. In 2012, nearly half of Medicare beneficiaries had annual incomes of below $22,500.

• Also starting in 2017, Obama’s plan would require new Medicare beneficiaries to pay $100 for five or more home health care visits that are not preceded by a stay in the hospital or another medical facility, such as a nursing home or a rehabilitation hospital. Home health care is one of the few areas in Medicare that does not have cost sharing, and its rapid growth in recent years has led panels like the Medicare Payment Advisory Commission (MedPAC) to recommend beneficiary cost sharing.

• Beginning in 2017, new beneficiaries who purchase supplemental insurance, known as Medigap, with particularly low cost-sharing requirements ­­– such as “first-dollar” coverage – will face a surcharge equivalent to approximately 15 percent of the average Medigap premium. The thought is that more generous Medigap plans encourage overuse of services, but seniors rely on these generous plans to shield them from unanticipated costs.

Joe Baker, president of the Medicare Rights Center, said that Medicare proposals that “increase deductibles and co-pays, and tax Medigap plans that ensure financial security, must be rejected.”

2. Wealthier Beneficiaries Pay More

Current law already requires individual beneficiaries whose incomes are $85,000 and above ($170,000 and above for couples) to pay a larger share of Medicare Part B (outpatient services like doctor visits and laboratory services) and Part D (prescription drugs) premiums. While most beneficiaries pay 25 percent of their Part B premiums, higher-income beneficiaries pay between 35 to 80 percent, depending on their income.

Obama’s plan would increase the lowest income-related premium to 40 percent and cap it at 90 percent. His plan would also maintain the current income thresholds until a quarter of Part B and Part D beneficiaries are paying the higher income-related premiums.

In a 2012 analysis, the Kaiser Family Foundation found that if the proposal to have a quarter of all beneficiaries pay the higher premiums were implemented last year, beneficiaries with incomes at or above $47,000 for individuals and $94,000 for couples would be paying higher income-related Medicare premiums. (KHN in an editorially independent program of the Foundation.)

The Obama administration says the proposal would help improve Medicare’s financial stability by reducing how much the government spends on Medicare for beneficiaries who can afford to pay more. But the Center for Medicare Advocacy fears asking higher-income people to pay a greater share of premiums “might lead to more people choosing not to participate in Medicare. Fewer participants in [Medicare] B and D would result in increased costs for the remaining participants.”

3. Doughnut Hole Closing Faster, Higher Drug Rebates for Low-Income Beneficiaries

• Obama’s budget plan would close by 2015 – instead of 2020 as mandated by the health law – the “doughnut hole,” that gap in Medicare prescription drug coverage where seniors pay the full cost of prescriptions until they hit a catastrophic cap. This acceleration would be financed by increasing the current 50 percent discount that the drug makers give to beneficiaries in the “doughnut hole” to 75 percent starting in 2015. Beneficiaries would be responsible for the remaining 25 percent of drug costs. Drug makers oppose raising the discount amount.

• The president’s proposal also alters drug costs for the nine million low-income Medicare beneficiaries who qualify for both Medicare and Medicaid. These people, known as “dual eligibles,” used to get their drug coverage from Medicaid, the shared federal-state health insurance program for the poor and disabled. And drug makers returned back to Medicaid in the form of rebates part of the cost of drugs for those beneficiaries, just as they do now for current Medicaid beneficiaries.

As part of the creation of the Medicare Part D prescription drug program, the drug coverage for “duals” shifted to Medicare. But the rebates that Medicare Part D plans negotiate are not as generous as those that drug makers previously paid to Medicaid, the administration says. Part D plans also pay higher prices for drugs than Medicaid does. The administration’s proposal would require drug makers to pay the difference between rebate levels they now provide to Part D plans and the Medicaid rebate levels.

In a statement, the Pharmaceutical Research and Manufacturers of America said the rebate proposal would increase beneficiary premiums and copays.

4. Provider Cuts

• Hospitals are none too happy about Obama’s plans to cut their Medicare payments for bad debt and graduate medical education over the next decade. Medicare now pays hospitals 65 percent of debts resulting from beneficiaries’ non-payment of deductibles and co-insurance after providers have made reasonable efforts to collect the money. Starting in 2014, the president’s plan would decrease that amount to 25 percent over three years, which the administration says would be closer to private payers that typically pay nothing on bad debt. The reductions would be in addition to those hospitals and other providers face as part of the 2010 health law.

• Beginning in 2014, the Obama plan also would cut by 10 percent “add-on” payments to teaching hospitals for graduate medical education.

In its budget document, the Department of Health and Human Services cites a MedPAC finding that these additional payments “significantly exceed the actual added patient care costs these hospitals incur.”

Hospital groups maintain that the cuts to bad debt reimbursement and medical education payments would weaken hospitals’ ability to provide care and to train physicians, nurses and other health professionals.

• Concerning payments to physicians, Obama’s budget assumes that Congress will once again pass a “doc fix” to avert a scheduled 25 percent payment cut in 2014. Administration officials say they want to work with Congress to find a long-range solution to avert the annual crisis over Medicare physician payments.

What Obama Left Out

• The president did not propose an increase in the Medicare eligibility age from 65 to 67, a savings mechanism favored by the GOP but assailed by some key Democrats.

• Nor did Obama propose combining the premiums beneficiaries pay for hospital care (Part A) and outpatient services (Part B). Taking that step, which has the support of Republican leaders like House Majority Leader Eric Cantor (R-Va.) would reduce Medicare expenditures and lower beneficiaries’ costs for hospital care. But seniors who mostly use Part B and don’t go to the hospital often would pay more.

Also of Interest

• 9 Things to Look for in the President’s Budget
• Sequester Fallout: Where Will Medicare Patients Get Chemo?
• Join AARP: Savings, resources and news for your well-being

See the AARP home page for deals, savings tips, trivia and more