ID Clinical Corner
The evolution of health care in the United States has included many changes, most of which have been driven by advances in the science of diagnostic and therapeutic medicine or pure economics. Driven by third party payors and the federal government, the clinical practice of medicine now routinely includes many intravenous therapies delivered to patients in nontraditional settings including physician offices, extended care facilities, and the home. Infectious diseases such as osteomyelitis, infective endocarditis, deep fungal infections, severe skin and soft tissue infections, and surgical wound infections are now commonly treated with intravenous antibiotics occasionally supplemented with a variety of cytokine therapies in nontraditional settings. The supervision and the liability of these therapies commonly fall onto the infectious disease (ID) physician, often with little or no compensation. Over the past 20 yeas, 3 distinct methods of providing this care have evolved and will be briefly discussed in this article.
As inpatient length of stays have shortened, hospitals have developed programs and facilities to allow them to continue to capture the health care dollars previously distributed to outside extended health care facilities and home care providers. Many hospitals have developed their own outpatient infusion services departments or formed joint ventures with existing home care companies. Traditionally, in this setting, the ID physician will dictate when the patient can safely be discharged to an alternate setting; prescribe the drug dosing and duration of therapy; order appropriate laboratory, radiographic, and other ancillary care such as wound therapy; and be available for consultation or follow-up therapy. Commonly, changes in the drug or dosing changes are necessary because toxicity or adverse events related to the initial therapy. Reporting of these adverse events, laboratory data, and nursing evaluations to the prescribing and responsible physician are all dependent on the agency providing the care. The prescribing physician has no control over these agencies but is liable for the care they provide. In the past, a physician may have been paid a consulting fee by one or more of these home care agencies, but decreasing revenues and the risk of "Stark Law self-referral" issues have virtually eliminated these arrangements. Hospitals, however, still employ many ID physicians for their expertise in infection control, antibiotic review, and quality assurance and may include supervisory duties in outpatient infusion services as part of the contractual obligations of the physician. In most instances, however, the physician provides these services with little or no reimbursement. There are current procedural terminology codes that allow monthly supervision charges to be submitted. Many physicians either do not bother to submit these charges because of the necessary documentation or are unaware that this potential reimbursement is available.
The second choice in providing outpatient infusion services is for the physician to own and supervise the services. This model (Outpatient Parenteral Antibiotic Therapy) has received considerable attention and endorsement by the Infectious Disease Society of America. The physician responsibilities and liabilities remain the same as in the hospital-directed model. However, the management and performance of this business are now in control of the physician or physician group. Patient satisfactory is generally high; medical errors decreased. The business profits are distributed to the physician owners. While physician's income is greatest with this model, so are the responsibilities and risks!
Unlike the hospital model, the physician or his employed manager must have the ability to hire and manage personnel including nurses trained in providing outpatient intravenous antibiotic therapy, perhaps a pharmacist experienced in outpatient intravenous antibiotic therapy, and certainly, billing and collection experts familiar with all the nuances of outpatient infusion therapy billing and collecting. Staying current with health care law is essential and, most often, will include substantial legal advice. This model is often viewed as being in direct competition with the hospital model, and political pressures within the hospital may make survival uncomfortable and competitive on a daily basis. The financial risks and time spent managing this model are great, but so are the potential rewards. Although less popular than 10 years ago, this model has not disappeared and is most commonly seen in large group practices that can support the personnel and other costs associated with the business.
The third model is a variation of the hospital model and the outpatient physician owned and managed model. As in the hospital model, the physician duties and liabilities associated with identifying and managing the patient are the same. The business, nursing, pharmacy, and billing and collecting services are all subcontracted through an outside company that shares the profits with the physician or physician group. Although the physician will require some accounting and legal support services with this model, they will be less than those with the Outpatient Parenteral Antimicrobial Therapy model. Reimbursement is theoretically less in this model as compared with that in the outpatient model but guaranteed to be more than that in the hospital model.
So which method is best for you?
1. Tice AD, Rehm SJ, et al. IDSA guidelines. Practice guidelines for outpatient parenteral antimicrobial therapy. Clin Infect Dis. June 15, 2004;38:1651-1672.
2. Trice AD, Slama TG, et al. Managed care and the infectious diseases specialist. Clin Infect Dis. 23;1996:341-368.
3. Stark P. HR 4520. Medical Physician Payment Reform Act. Available at: www.house.gov
4. Stark P. An overview of Representative Stark's vision of health care reform. Health care reform update. Am Fam Physician. May 1, 1994.