Obtaining ABNs and implementing an effective process

In the current healthcare environment, it is critical that healthcare providers get every penny to which they are entitled. It seems that each year healthcare providers are forced to do more with less and imaging services in particular have taken a huge hit in reimbursement starting back in 2005 with the implementation of the Deficit Reduction Act (DRA). Payment reductions will likely continue over the next several years. One way to optimize revenue is to ensure that Advance Beneficiary Notices (ABNs) are being obtained in an effort to receive payment for services that may not be medically necessary. This article focuses on requirements for using the ABN and provides tips for implementing an effective process for monitoring medical necessity denials.

Medical imaging as a contributor to today's healthcare crisis

At the end of 2007, Medicare reported the increase in medical imaging costs overtook increases in pharmaceutical costs for the first time. Imaging costs accounted for a 20% increase, while pharmaceuticals accounted for just 10%. There are two common areas where imaging costs impact overall healthcare spending: unnecessary exams and operational management. This article does not suggest alternatives to today's imaging management practices. It provides economic information, which may be valuable to imaging managers who want to gauge the costs of operating their own departments to what is going on in the industry.

[Appropriate use of laboratory tests--medical aspects]

BACKGROUND

There has been a large increase in the use and costs of laboratory tests during recent years. Several reports have indicated excessive and inappropriate use. The purpose of this study was to assess the use of public laboratory services within clinical chemistry in two Norwegian health regions.

MATERIAL AND METHODS

Production statistics for 2004 were obtained through a questionnaire sent to all public clinical chemistry hospital laboratories in northern and western Norway. Additional detailed production statistics were obtained from Haukeland University Hospital for 2002-04.

RESULTS

We observed differences in the absolute frequency of requested tests and a marked variation in relative ratios (ratio between related tests) between the laboratories in northern and western Norway. Data from Haukeland University Hospital showed a mean increase of 12% (range: -24-54%) in the number of ordered tests between 2002-04.

INTERPRETATION

There are no known differences in morbidity between the northern and western health regions that can explain the observed variations in the use of laboratory tests. Our observations indicate a need for a thorough investigation of current utilisation of laboratory tests. Initiatives should be taken on a national basis to improve appropriate use.

Referral of patients with iron deficiency anaemia under the lower gastrointestinal two-week wait rule

OBJECTIVE

One of the 2-week wait (2WW) criteria for suspected lower gastrointestinal cancer states that patients should be referred who have iron deficiency anaemia (IDA) without obvious cause [Haemoglobin (Hb) <11 g/dl men, <10 g/dl postmenopausal women].

AIM

Our aim was to find the proportion of patients referred as a 2WW not meeting the criteria, and the cost accrued by unnecessary referral.

METHOD

Patients referred over 1 year were identified using the hospitals cancer database. Haematology, haematinics, coeliac serology and cancer status were recorded for each patient.

RESULTS

A total of 204 patients were referred. In total, only 22/204 patients (10.8%) met all the necessary criteria for diagnosis and investigation of IDA prior to referral. As only 43/204 (21.1%) had been assessed for coeliac serology, this accounted for the majority of incomplete referrals. Excluding coeliac serology, only 127 (62.3%) met 2WW criteria for IDA. Of the remaining 77 patients, 57 (74%) patients did not meet the 2WW criteria on Hb alone and 35/77 were referred with no evidence of IDA. 12/127 (9.4%) patients were diagnosed with colorectal cancer. No cancers were detected in patients without BSG evidence of IDA, although one patient did not meet the criteria on Hb level alone.

CONCLUSION

Although iron deficiency is a good marker for gastrointestinal cancer, it is evident that 2WW referral guidelines are not being followed. 89.2% of referrals are inappropriate according to guidelines. This not only has considerable workload and financial implications but could be potentially detrimental to patient health.

Laboratory testing in the intensive care unit

Laboratory testing is ubiquitous among hospitalized patients and is more common among patients in the intensive care unit (ICU). Despite its high cost and prevalence, there are few data to support the current practice of laboratory testing in most ICUs. Although testing offers considerable potential benefits, it is not without risk, including misleading results, iatrogenic anemia, and therapeutic actions of uncertain benefit. Laboratory testing should be conducted as part of a therapeutic approach to a clinical problem, mindful of pretest probability of disease, the performance of the selected test, and the relative benefits and risks of testing. Considering the indication for a particular test can lead to a more rational approach to laboratory testing and better use of available tests.

Health economic evaluation of ferucarbotran-enhanced MRI in the diagnosis of liver metastases in colorectal cancer patients

PURPOSE

The objective of our study was to analyze the health economic impact of ferucarbotran-enhanced magnetic resonance imaging (MRI) in the diagnosis of hepatic colorectal cancer metastases based on observed changes in medical management.

MATERIALS AND METHODS

A decision tree simulating a patient's medical management was designed, comparing two scenarios: contrast-enhanced spiral computed tomography-based vs ferucarbotran-enhanced MRI-based (Resovist, Bayer Schering Pharma AG, Germany) diagnosis. A clinical trial in patients with presumed liver metastases (n=36) provided data on clinical decisions regarding the medical management options in relation to diagnostic outcomes: resection, chemotherapy, or best supportive care. A "gold standard" was established afterward, combining all the available clinical, imaging, laboratory, and pathology findings. A multidisciplinary panel formed by a hepatologist, a liver surgeon, and an interventional radiologist decided on the recommended medical management for each patient. Costs of medical resources associated with each management option (all expressed in Euro) were obtained from the public health insurance (average European values). Life expectancies for the different options were obtained from literature.

RESULTS

Despite an initial extra cost of 338 Euro, a significant net saving of 1,443 Euro was obtained with ferucarbotran-enhanced MRI mainly because of avoiding unnecessary surgery. There was no significant difference in the predicted life expectancy between both arms, despite the large difference in medical decision.

CONCLUSION

In this comparative medical decision analysis, it was shown that ferucarbotran-enhanced MRI has the potential to improve medical management and save health care costs.

Extending the P4P agenda, part 1: how Medicare can improve patient decision making and reduce unnecessary care

The decision to undergo many discretionary medical treatments should be based on informed patient choice. Shared decision making is an effective strategy for achieving this goal. The Centers for Medicare and Medicaid Services (CMS) should extend its pay-for-performance (P4P) agenda to assure that all Americans have access to a certified shared decision-making process. This paper outlines a strategy to achieve informed patient choice as the standard of practice for preference-sensitive care.

Cost-effectiveness of reduced follow-up in malignant melanoma

BACKGROUND

Considerable variability exists in the extent and frequency of follow- up examinations for melanoma patients between different countries, generating significantly different total costs and uncertain clinical benefits.

PATIENTS AND METHODS

We have analyzed the follow-up of melanoma patients under clinical and economic aspects based on the latest recommendations of the American Joint Committee on Cancer (AJCC) and the German Dermatologic Society (DDG) in the Düsseldorf cohort of 526 patients (stage IIII) during a 5-year follow-up period. Outcome measures were frequency of metastasis detection, most effective detection method, costs per detected metastasis and cost per quality-adjusted life year.

RESULTS

Structured follow-up detected 17 recurrences in stages I-III. Physical examination and lymph node ultrasound were the only cost-effective methods at all stages, while laboratory studies were generally not cost-effective. The implementation of a reduced, yet medically adequate follow-up reducing chest X-rays, abdominal ultrasound examinations and eliminating blood tests in early stages yielded savings of more than 100,000 euro (120,000 $) annually at a tertiary care university hospital.

CONCLUSION

The implementation of a reduced follow-up for melanoma patients seems not only medically justified but also economically required without adversely affecting patient outcome.

[Outcomes research: definitions, methods and challenges in trauma and orthopaedic surgery]

BACKGROUND

Besides basic, illness- and patient-oriented research, outcomes research is regarded as the fourth pillar of modern health care systems. Outcomes research investigates both the desirable and adverse effects of medical and surgical interventions under day-to-day conditions.

METHOD

Because of rigorous entry criteria and selection of eligible subjects, the efficacy of a certain treatment derived from clinical experiments (i.e. classic randomized trials) may not necessarily be transferred to common patient populations or clinical settings. Apart from efficacy, a valuable (thus reimbursable) diagnostic or therapeutic procedure must prove its effectiveness in clinical practice as well. Demanding study designs are necessary to model effectiveness and to separate the observed intervention-related effects from bias and confounding.

RESULTS

Registries and pragmatic randomized trials may represent the most appropriate modalities to establish outcomes research in trauma and orthopaedic surgery. Good examples for interventions still needing proof of effectiveness are kyphoplasty and vertebroplasty, navigated surgery, damage control, interlocking implants and bone growth factors. Revealing over- and undersupply, generating negative lists (i.e. interventions of questionable or almost nil effectiveness) and integrating patients as co-therapists requires networking between hospitals and private practitioners.

CONCLUSION

Also, since outcomes research is a societal need, its development and funding must be ensured by all providers and payers of health care services.

The prophylactic extraction of third molars: a public health hazard

Ten million third molars (wisdom teeth) are extracted from approximately 5 million people in the United States each year at an annual cost of over $3 billion. In addition, more than 11 million patient days of "standard discomfort or disability"--pain, swelling, bruising, and malaise--result postoperatively, and more than 11000 people suffer permanent paresthesia--numbness of the lip, tongue, and cheek--as a consequence of nerve injury during the surgery. At least two thirds of these extractions, associated costs, and injuries are unnecessary, constituting a silent epidemic of iatrogenic injury that afflicts tens of thousands of people with lifelong discomfort and disability. Avoidance of prophylactic extraction of third molars can prevent this public health hazard.

The inappropriate use of imaging studies: a report of the 2004 Intersociety Conference

The participants of the 2004 Intersociety Conference met to discuss the growing problem of self-referral. The United States spends more of its gross national product on health care than other countries, especially Japan and those in Western Europe. Imaging accounts for a large and growing portion of those costs. Despite spending so much on health care, the United States ranks relatively low in measures of national health, including such parameters as infant mortality and even life expectancy. Because the federal government must keep health care expenditures to a "sustainable growth rate," increases in use are likely to be accompanied by decreases in reimbursement per case. Thus, conference participants agreed that the real problem is inappropriate use, which may arise from (1) ignorance of what specific imaging studies are needed when, (2) high public expectations for imaging tests, (3) the fear of liability for a missed diagnosis (defensive medicine), and (4) self-referral. The Stark laws have been largely ineffective in preventing self-referral because there are many loopholes, and the laws are inconsistently enforced. Among the many potential solutions are the education of our clinical colleagues on appropriateness criteria; the education of the public on the costs of inappropriate use; tort reform; and working with third-party payers, especially the private insurance industry, to develop vigorous privileging programs, to require precertification for self-referred studies, or to establish differential payments for self-referred and non-self-referred imaging.

Geld und Dialyse

Chronic renal replacement therapy by hemodialysis costs 55,000 Euros per year and constitutes the upper limit of a cost-effective treatment. Since reimbursement for dialysis is high, every patient who is in need of it will receive dialysis. Nephrology outside the hospital, however, is moving into a progress trap. Financial incentives tempt physicians to avoid complex or delicate treatments such as immunosuppression of IgA nephritis. The decision to forgo or withdraw dialysis and the referral to kidney transplantation conflict with the nephrologists' economic interests. High-tech medicine needs a shift in thinking since not all medically possible diagnostic and therapeutic procedures can be financed anymore. The costs urge to do more for prevention and treatment of kidney disease. Alternative possibilities to extend the cost-effective kidney transplantation should be discussed without moral rigorism. Since it is in competition with other cost-intensive disciplines, it is hard for nephrologists to start with the required mind-changing process.

Corrupt practices in chinese medical care: the root in public policies and a call for Confucian-market approach

This paper argues that three salient corrupt practices that mark contemporary Chinese health care, namely the over-prescription of indicated drugs, the prescription of more expensive forms of medication and more expensive diagnostic work-ups than needed, and illegal cash payments to physicians-i.e., red packages-result not from the introduction of the market to China, but from two clusters of circumstances. First, there has been a loss of the Confucian appreciation of the proper role of financial reward for good health care. Second, misguided governmental policies have distorted the behavior of physicians and hospitals. The distorting policies include (1) setting very low salaries for physicians, (2) providing bonuses to physicians and profits to hospitals from the excessive prescription of drugs and the use of more expensive drugs and unnecessary expensive diagnostic procedures, and (3) prohibiting payments by patients to physicians for higher quality care. The latter problem is complicated by policies that do not allow the use of governmental insurance and funds from medical savings accounts in private hospitals as well as other policies that fail to create a level playing field for both private and government hospitals. The corrupt practices currently characterizing Chinese health care will require not only abolishing the distorting governmental policies but also drawing on Confucian moral resources to establish a rightly directed appreciation of the proper place of financial reward in the practice of medicine.

[Unnecessary test repeats in viral hepatitis serology]

Inappropriate laboratory testing constitutes a vast burden regarding the cost and the workload for health care system. Unnecessary repetition of tests is one of the most common reasons accounting for inappropriate laboratory utilization. A wide spectrum of tests are utilized to diagnose hepatitis A and B infections in Turkey because of the high seroprevalence rates. The present research aimed to determine the rate of unnecessary repeat testing of anti-HAV total and anti-HBc used in serological diagnosis of hepatitis A and B infections and to discuss the possible solutions for this problem. Laboratory records of the serology laboratory of Dokuz Eylul University Hospital, dating between May 2002 - May 2005, were evaluated retrospectively. Unnecessary repeat testing was defined as the repetition of anti-HAV total and/or anti-HBc for the patients positive for one or both of the tests. During the study period of three years, a total of 10.658 anti-HAV total and 13.047 anti-HBc were tested of which 8.550 (80%) and 4.959 (38%) were found positive, respectively. Out of the positive results, 1.197 (14%) anti-HAV total and 904 (18%) anti-HBc tests were detected to be unnecessarily repeated tests. The estimated cost of a total of 2101 unnecessarily repeated tests was found approximately 17.000 US Dollars. Our data display that considerable amount of unnecessary testing takes place in serological testing of viral hepatitis. Prevention of inappropriate laboratory requests by clinicians would help to diminish the work load in serology laboratories and the cost both for the hospitals and the country.

[An analysis of avoidable admissions to a neurology service]

INTRODUCTION

Inappropriate admissions to a hospital service generate unnecessary costs for our health care service. Most admissions to a hospital service come from the emergency department. The presence of a neurologist to attend hospital emergencies would be an important factor allowing admission criteria to be streamlined.

AIMS

To determine the number of avoidable admissions (AA) in a neurology service, and to define their characteristics.

PATIENTS AND METHODS

We conducted a prospective, descriptive study of the admissions that took place in the Neurology Service of the Hospital General Universitario de Elche (Alicante) over a period of three months. The neurologist determines whether admission is indicated or not. We collected demographic data concerning the patient, the admission diagnosis, neurological diagnosis, the reason for appropriateness and the reason for AA.

RESULTS

A total of 250 admissions were attended; 65 were considered to be AA (26%). The most frequent diagnoses in the cases of AA were non-neurological (32.3%), clinical findings (15.4%), neuropathies (10.8%) and epilepsy (10.8%). The reasons leading to AA were non-neurological and transfer to another service (30.8%), follow-up by neurology outpatient department (NOD) (29.2%), NOD study (21.5%), non-neurological and discharge (16.9%) and not specified (1.5%). The mean length of stay in the case of AA was 4.3 days.

CONCLUSIONS

The number of AA in our service is higher than that found in other studies. On-duty neurologists, streamlining outpatient diagnostic testing and the design of flexible schedules for outpatient care would reduce the amount of resources that are used, while at the same time increasing the quality of the health service.

Hand injury costs

Injuries of the hand are common accounting for around a fifth of all emergencies presenting to emergency departments of most hospitals. Their treatment costs. Those that require more reconstruction, theatre time, stay in hospital and after care cost more. In the UK, over 100 million pounds is being spent per year in treating these injuries. However indirect expense to the patients and the consequences of permanent disability are seldom considered. This review discusses the direct and indirect costs of hand injury, the ability of countries to pay these costs and suggests some ways of minimising these costs.

The impact of fetal fibronectin testing for women with symptoms of preterm labour in routine clinical practice within a New Zealand population

AIMS

To perform a comparative analysis of antenatal management received according to the results of cervico-vaginal fetal fibronectin (fFN) testing, and to review preterm delivery rates and fFN predictive values within a New Zealand population of women presenting with threatened preterm labour.

METHODS

Case note review of all fFN tests performed at Middlemore Hospital, South Auckland from August 2003 to March 2005 (n = 199). Data collected included risk factors for preterm delivery, signs and symptoms at presentation, antenatal management received after fFN test and outcome and delivery details. Positive and negative fFN results were compared.

RESULTS

Women with a positive fFN were more likely to receive antenatal corticosteroids (96.4 vs 4.7% RR 8.74 (95% CI 5.40-14.17)) and tocolysis (71.4 vs 2.4% RR 8.10 (95% CI 4.49-14.59)) and to be admitted antenatally (96.4 vs 54.4% RR 1.77 (95% CI 1.50-2.10)) with a higher mean cost of treatment (967.47 NZ dollars vs 335.27 NZ dollars P < 0.05). Rates of delivery < 34 weeks were higher in those with a positive fFN (41.9 vs 0.7% RR 62.06 (95% CI 8.43-457.14)).

CONCLUSION

Women with a positive fFN result received different treatment to those with a negative fFN. Use of fFN test in routine clinical practice allows management and resources to be targeted more appropriately and may limit unnecessary interventions.

Reducing unnecessary inpatient laboratory testing in a teaching hospital

After an inpatient phlebotomy-laboratory test request audit for 2 general inpatient wards identified 5 tests commonly ordered on a recurring basis, a multidisciplinary committee developed a proposal to minimize unnecessary phlebotomies and laboratory tests by reconfiguring the electronic order function to limit phlebotomy-laboratory test requests to occur singly or to recur within one 24-hour window. The proposal was implemented in June 2003. Comparison of fiscal year volume data from before (2002-2003) and after (2003-2004) implementation revealed 72,639 (12.0%) fewer inpatient tests, of which 41,765 (57.5%) were related directly to decreases in the 5 tests frequently ordered on a recurring basis. Because the electronic order function changes did not completely eliminate unnecessary testing, we concluded that the decrease in inpatient testing represented a minimum amount of unnecessary inpatient laboratory tests. We also observed 17,207 (21.4%) fewer inpatient phlebotomies, a decrease sustained in fiscal year 20042005. Labor savings allowed us to redirect phlebotomists to our understaffed outpatient phlebotomy service.

Avoidable hospitalisations: potential for primary and public health initiatives in Canterbury, New Zealand

AIM

To investigate the extent of potentially "avoidable hospitalisations" in the Canterbury District Health Board area; specifically, to identify the leading causes, recent trends, and estimated costs of avoidable hospitalisations.

METHODS

All hospitalisations in Christchurch Hospital from 2000 to 2004 were analysed and potentially "avoidable admissions" were categorised using ICD10 clinical codes. Costs of these admissions were estimated for the financial year ending 30 June 2003 using diagnostic-related groups (DRGs).

RESULTS

The leading causes of potentially "avoidable hospitalisations" in Christchurch Hospital were cardiovascular disease, stroke, respiratory, gastrointestinal, and urinary disorders. The total estimated costs of avoidable hospitalisations in 2003 were NZ 96.6 million dollars, accounting for an estimated 94,462 bed days. The estimated costs of cardiovascular admissions (excluding stroke) were 50.6 million dollars, with stroke accounting for an additional 6.2 million dollars.

CONCLUSION

Potentially "avoidable admissions" to Christchurch Hospital comprised 31% of all hospital admissions. There is considerable opportunity to invest in public and primary health initiatives aimed at early detection and intervention, with the major opportunities being identified as cardiovascular disease, stroke, respiratory, gastrointestinal, and urinary disorders.

Verhaltensänderung durch Einführung der Praxisgebühr und Ursachenforschung

As part of the Statutory Health Insurance Modernization Act a co-payment of 10 Euros per quarter for the first contact at a physician's or a dentist's office has been introduced with effect of January 1, 2004. Apart from contributing to the financial consolidation of the Statutory Health Insurance the co-payment aimed at changing the patients' behavior toward more self-responsibility. This article shows that physician contacts declined in the year 2004 compared to 2003. However, the share of those patients who had at least one physician contact in both years remained stable. Two Logit models point out that necessary physician contacts still take place, e. g., in case of disabled persons and persons with poor health. In addition, no discrimination of persons of low social status could be observed. The results are also approved by other studies. Therefore, it seems plausible, that the introduction of this co-payment has contributed to a reduction of unnecessary and redundant physician visits.

Cost-consciousness among Swiss doctors: a cross-sectional survey

Background

Knowing what influences physicians attitudes toward health care costs is an important matter, because most health care expenditures are the results of doctors' decisions. Many decisions regarding medical tests and treatments are influenced by factors other than the expected benefit to the patient, including the doctor's demographic characteristics and concerns about cost and income.

Methods

Doctors (n = 1184) in Geneva, Switzerland, answered questions about their cost-consciousness, practice patterns (medical specialty, public.vs. private sector, number of patients per week, time spent with a new patient), work satisfaction, and stress from uncertainty. General linear models were used to identify independent risk factors of higher cost-consciousness.

Results

Most doctors agreed that trying to contain costs was their responsibility ("agree" or "totally agree": 90%) and that they should take a more prominent role in limiting the use of unnecessary tests (92%); most disagreed that doctors are too busy to worry about costs (69%) and that the cost of health care is only important if the patient has to pay for it out-of-pocket (88%). In multivariate analyses, cost-consciousness was higher among doctors in the public sector, those who saw fewer patients per week, who were most tolerant of uncertainty, and who were most satisfied with their work.

Conclusion

Thus even in a setting with very high health care expenditures, doctors' stated cost-consciousness appeared to be generally high, even though it was not uniformly distributed among them.

High and rising health care costs. Part 4: can costs be controlled while preserving quality?

Several interrelated strategies involving physician leadership and participation have been proposed to contain health care costs while preserving or improving quality. These include programs targeting the 10% of the population that incurs 70% of health care expenditures, disease management programs to prevent costly complications of chronic conditions, efforts to reduce medical errors, the strengthening of primary care practice, decision support tools to avoid inappropriate services, and improved diffusion of technology assessment. An example of a cost-reducing, quality-enhancing program is post-hospital nurse monitoring and intervention for patients at high risk for repeated hospitalization for congestive heart failure. Disease management programs that target groups with a chronic condition rather than focusing efforts on high-utilizing individuals may be effective in improving quality but may not reduce costs. Error reduction has great potential to improve quality while reducing costs, although the probable cost reduction is a small portion of national health care expenditures. Access to primary care has been shown to correlate with reduced hospital use while preserving quality. Inappropriate care and overuse of new technologies can be reduced through shared decision-making between well-informed physicians and patients. Physicians have a central role to play in fostering these quality-enhancing strategies that can help to slow the growth of health care expenditures.

Value of anaerobic blood cultures in pediatrics

The aim of the study presented here was to evaluate the utility of anaerobically incubated blood cultures for detecting infections in pediatric patients. During a 2-year period 9,165 pediatric blood samples were processed, and significant microorganisms were recovered from 497 (5.4%) of them. Only two of the microorganisms isolated were strictly anaerobic. Of the total isolates, 13% were detected in anaerobic bottles solely. Considering that the quantity of blood available from pediatric patients for blood cultures is usually small, it may be reasonable to limit the use of anaerobic blood cultures to patients with the highest risk.

Health insurers’ medical necessity determinations for bariatric surgery

PURPOSE

This study explored how state managed-care patient protection laws affect health insurers' criteria for medical necessity, using bariatric surgery for weight reduction as a case in point.

METHODS

Six states and three national insurers were selected for in-depth case studies to represent a range of market, demographic, and legal conditions. In each state, 10-12 qualitative interviews were conducted in 2002 with insurers, regulators, providers, and healthcare attorneys, for a total of 71 interview subjects.

RESULTS

Denials of coverage for bariatric surgery are a frequent source of appeals to external review, and external reviewers frequently overturn these denials. However, few insurers feel pressured to approve most or all requests for coverage because external review decisions do not set binding precedents. Instead, insurers continue to assert their own criteria for medical necessity, relying on the insurance contract's general definition of medical necessity. Some insurers, however, specifically exclude all weight reduction surgery because of the difficulty of defending case-by-case denials on appeal.

CONCLUSIONS

Unlike most areas of medicine, in which health insurers have greatly scaled back their past efforts to scrutinize medical necessity, for bariatric surgery, many insurers continue to apply a more stringent standard for medical necessity than the one that independent practicing physicians use.

Picking up the tab. Healthcare chains put the past behind them, resolving past unpleasantries in order to make a clean start in the new year

It's something of a holiday tradition: legal settlements at major investor-owned healthcare companies. But will Tenet's and HealthSouth's multimillion-dollar mea culpas over allegations of providing unnecessary care have the same healing effect that HCA's pair of year-end settlements yielded? Tenet's E. Peter Urbanowicz, left, said his company's moves show "the real progress we are making to put our legal challenges ... behind us".