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Wednesday, August 25, 2010

Extra Extra Read All About It

Today’s online edition of the New England Journal of Medicine has two articles, one by Katherine Sebelius regarding the recent health reform legislation in the United States, and another article  by Nick Black, M.D. on the United Kingdom’s proposed  changes to the NHS.

The appearance of these two articles with almost inexplicable timing  reveals how two different systems see themselves as failures and are seeking to correct it by going in opposite directions. 

It begs the question, “Who is ahead in creating a ‘more perfect world?”

So goes California…so goes the Nation

or why we need less government.

The remainder of this post has been removed at the request of the copyright holder. Modern Medicine holds the rights to the content, and we are negotiating with them to license some portions of their material for this blog. Sorry.

Tuesday, August 24, 2010

Power to the People !!???

What people you may ask?  Ask and ye shall be told !!

Modern Medicine announced today the 100 MOST POWERFUL PEOPLE IN MEDICINE.

So, who makes  this momentous decision?? Is it more important than the ‘Golden Llama Award’?? (of which I unashamedly boast that I earned some time ago)

A little bit of research reveals that these mighty Centurions are chosen in this manner. 

Is it any wonder why most physicians are enraged and stand gawking with disbelief?

Dr Wes, in his blog today points out how the rules don’t count for those who make the rules

Should Dr. Emanuel not have noted his relationship as White House advisor for health care policy and his relationship with his brother, White House Chief of Staff Rahm Emanuel? And should Ms. DeParle's disclosed her role as President Obama's so-called health czar with significant ties to private equity firms?

Conflict of interest exists when an author, editor, or peer reviewer has a competing interest that could unduly influence (or be perceived to do so) his or her responsibilities in the publication process. The potential for an author’s conflict of interest exists when he or she (or the author’s institution or employer) has personal or financial relationships that could influence (bias) his or her actions. These relationships vary from those with negligible potential to influence judgment to those with great potential to influence judgment. Not all relationships represent true conflict of interest. Conflict of interest can exist whether or not an individual believes that the relationship affects his or her scientific judgment.
Authors, editors, and peer reviewers must state explicitly whether potential conflicts do or do not exist. Academic, financial, institutional, and personal relationships (such as employment, consultancies, close colleague or family ties, honoraria for advice or public speaking, service on advisory boards or medical education companies, stock ownership or options, paid expert testimony, grants or patents received or pending, and royalties) are potential conflicts of interest that could undermine the credibility of the journal, the authors, and science itself.

Perhaps such disclosures only for the little people in health care who try to publish their work.

 

And finally  Dr Wes offers this list as the 10 most important (and powerful ) people in Medicine:

So who are the most powerful people in health care?
Well, I'd like to propose my list - maybe not of a 100 people (frankly, nothing gets done if you have a committee of 100 people anyway) - but rather my own list of the Top 10 Most Powerful People in Your Health Care today:

10. The Doctor - They consider the differential, write the orders, follow-up on tests, and move the health care ball forward throughout your hospitalization or stay with a rehab facility. As such, they should be given their power due, even if many other members of the health care team are actually are the ones that make sure the care happens. Still, because the doctor gets most of the liability risk if things don't happen or happen incorrectly, they just make my power list.
9. The Food Service Personnel - These folks are powerful. They have the ability to make even a clear liquid diet look like real food - especially when they mix the colors and flavors of jello. Further, proper parenteral nutrition for an ICD patient greatly shortens the sickest patient's hospitalization. Get it right and everyone benefits. Power personified.
8. The Physical Therapist - If you can't eat your food, sit up, keep your muscles toned, maintain the range of motion of your limbs when sick, the chances of returning to independent living are limited. Physical therapist have come of the most helpful techniques to get going - both physically and mentally - like turkey bowling. Their power over our patients should definitely be appreciated more.
7. The Social Worker - Want to negotiate the complex Medicare and Medicaid rules for placement in an assisted living facility? Need to get a patient to rehab? Want to arrange transportation for a patient that doesn't have a penny to their name? Make something from absolutely nothing? Call the Social Worker - but call them early in the hospital stay. (They're never at their best with last-minute consults.)
6. The Nursing Supervisor - Trust me on this. No one has more power to assure adequate staffing on each patient care ward each day than the Nursing Supervisor. Medical students and residents that cross the directives issued by this individual do so at their own peril.
5. The Bed Coordinator - If you need to admit a patient to a hospital, they must first get a bed. With many hospitals working at or near capacity, no single person has more influence over the patients admitted to a hospital facility. They find beds when no one else can. After all, it's their job.
4. The Hospital Operator - Name one person who can activate a Code Blue (cardiac arrest), find the obscure specialist in the middle of the night when they're most needed, or mobilize a trauma team faster. Can't do it? That, my friends, is power.
3. The Night Shift Nurse - At three in the morning when you're lying there in the hospital bed and need something - anything - who's the most important person in the hospital who will assure you're needs are tended to? Need I say more? If the night shift nurse is inattentive, unresponsive, irresponsible for that 8-hour shift - you're screwed. On the other hand, if she's attentive, knows when to call for help, or provides pain relief when you need it most after surgery, or - most important - gives you that laxative at 3AM - his or her power in medicine pales in comparison to any bureaucrat, politician, or hospital system CEO.
2. The Patient's Family - Often forgotten, family members have huge influence over the care provided to their loved one - especially at times where their loved one might not be able to communicate. This power should not be ignored, but it cuts both ways, too. While family members can facilitate the treatment and rehabilitation of their loved one because they know them better than anyone else, they can also prolong undue suffering if they do not comprehend the limits of care that their loved one desires in the end-of-life setting. Families that communicate their needs and wishes before anyone gets sick avoid much of the confusion during this difficult time and serve as powerful allies to the health care team.
1. You, The Patient - No one has more influence and power over their care than you. Don't want care? Leave. No one can stop you. Want care and don't have a penny? Come to the Emergency Room. You won't be turned away. Wonder what all the big buildings, waterfalls, and fancy technology were built and bought for? You. Every single person involved in health care is there because of you. So make the most of it. Come prepared. Know your medical history, medicines and allergies. If you can't remember, keep a list with you. Ask questions. Insist on clear answers. Work with your care givers, don't fight them. If you're not sure, get a second opinion. Write a letter acknowledging those that made the extra effort and scolding those that didn't. Your constructive criticism makes the system better. And know that hospitals understand the importance of your word-of-mouth referral - it's the most powerful marketing strategy a health care system can generate. Finally, remember that you can vote for politicians that don't forget who's in charge. You are the ultimate power broker in health care. Don't forget it.

-Wes

Musings of a cardiologist and cardiac electro physiologist.

And Thank you to the most powerful electophysiologist in the blog world….make my milliamps…Dr Wes

Health Reform in the NHS vs.. The U.S.

 

image         image

 

Surprise!! The U.K.s NHS system is running away from itself as fast as Obama and Berwick are running toward an obsolete model.

From the  BBC News Online  today,

image

Hospitals are to be set free from central control

 

“Unison has launched legal action against the government's plans for a major shake-up of the NHS system in England.

The UK's largest public service union claims ministers failed to ask the public if it wanted such fundamental changes in the first place.

The proposals in the health White Paper would hand the responsibility for most health services to GPs.

A consultation on how the changes would be implemented ends on 5 October 2010.

A Department of Health spokeswoman said the government was engaging fully with the public, healthcare professionals, local authorities and unions on how its proposals will be implemented.

Continue reading the main story

“Start Quote

Far from liberating the NHS, these proposals will tie it up in knots for years to come - they are a recipe for more privatization and less stability”

End Quote Karen Jennings Unison

But Unison argues the public's view on the White Paper proposals has not being requested and will not be considered.

Karen Jennings, Unison head of health, said: "The White Paper contains sweeping changes to the NHS and how it should be run.

Continue reading the main story

Related stories

"The NHS Constitution enshrines the principle that the public, staff and unions have an absolute right to be consulted. And that means not only on how the proposals are to be implemented, but also whether they should go ahead in the first place.

"The Department of Health's refusal to recognize this clear and important legal duty leaves us no option but to issue legal proceedings as a matter of urgency."

Unison said that the day after the White Paper was published, NHS chief executive Sir David Nicholson wrote to all NHS chief executives instructing them to start implementing the proposals "immediately".

The union maintains this was unlawful, but the Department of Health disagrees.

A spokeswoman said Sir David Nicholson's letter encouraged the NHS to begin locally led consultations and take first steps on the implementation of the White Paper, without pre-empting the wider consultation.

"Many reforms are also subject to Parliamentary approval as part of the Health Bill.

"Through the proposed changes, healthcare professionals and patients will have more power to shape, lead and deliver local healthcare services, away from the control of central Government," she said. (emphasis mine)

Unison believes the White Paper opens the door to privatization of the health service, and warns it would plunge the NHS into "chaos".

Ms Jennings said: "Far from liberating the NHS, these proposals will tie it up in knots for years to come - they are a recipe for more privatization and less stability."

 

It seems the U.K. NHS has it’s own problems with transparency and changes. 

LiveJournal Tags: ,,,

Sunday, August 22, 2010

Innovation

It goes something like this:

Bill Gates:

 

So, the underlying question is what will Obamacare do for innovation in health care.

 

Perhaps it will drive further innovation to radically change our paradigm for delivering healthcare and improving wellness.

Did congress set off the spark for innovation?

Will innovators enter medical practice?

Tuesday, August 17, 2010

Diabetes and it’s Complications

Normally I post articles on health reform, and information technology.

However today I was in the process of preparing examination questions for board preparation for the American Board of Ophthalmoloogy, and came upon this poignant observation by a medical resident.

It also points out the importance of tight glycemic control for diabetic patients.

Insight

Elizabeth B. Gay, MD
Charlottesville, Virginia
eg3d@hscmail.mcc.virginia.edu

JAMA. 2010;303(3):205.

The right eye bleeds on a Wednesday morning. I am walking to clinic, heading up the hill on 97th Street. For a moment, I imagine the dark spot is some trick of light and shadow. But it grows before me, spreading outward from its center, forming a web across my vision.

I know the correct medical language—vitreal hemorrhage—

but can only think: My eye is bleeding. The growing web floats across the world, almost beautiful if I weren't so afraid. I had a laser treatment on this eye two days ago, to prevent fragile new vessels from bleeding.

The right eye has always been the good eye; the left has been bleeding for a year, despite more laser sessions than I can count. I know I will need a vitrectomy

 

on the left eye, but I was counting on the right. This bleeding is the result of diabetic retinopathy and so particularly painful because it is in part my fault. Previously obsessive about my blood glucose, during my intern year of medicine residency, exhilarated and exhausted by the rigors of training, I struggled for reasonable control. And I let myself be 180 rather than 80, given the inconvenience of being low. My blurry vision feels like punishment, and usually I believe it's deserved.

I keep walking to clinic because there's nothing to be done right away—I can't have more laser after only two days. It is a perfect fall day, clear and sunny, but it is disappearing under a growing darkness. I am afraid that I will never again experience this sharp morning light, that I will always remember this morning as a moment of loss. Practical concerns add to my sense of despair: I’m on call for the ICU in two days, and the vision in my left eye is already blurry. I need the right eye to function. Of course this need doesn't matter, the body impervious to my panicked mind.

Clinic is chaotic as usual, and I abandon any attempt to read scribbled chart notes. On the computer I enlarge the font, grateful for modern technology. And most of what I need to know, patients tell me. Somehow the day goes on. This is how it's done, this is how people cope with illness. You go on because there is no choice. You go to work and do the best you can. Medicine is a good job because it's easy to forget yourself. Working in the ICU on Thanksgiving Day, I tell myself that the threat of blindness is less than what my patients face. I hold in my mind images of bravery offered to me every day, families who pull together to make unbearable decisions about the end of life, patients who somehow find pleasure in being an "interesting patient." But I can't quite convince myself. I would prefer the threat of death to that of blindness. Reading for me seems as essential as breathing, as impossible to live without. And then there is this: What if I can't do the job I’ve been working toward for eight years? But it is more than that because it's somehow become more than a job: it's become who I am. I am afraid that if I can't be a physician, I will lose my self.

I am saved by medicine after all, by a superb ophthalmologist and his colleague who skillfully remove the vitreous of my left, then my right eye. After each operation I must keep my head parallel to the floor for three days. This is the posture of defeat, the posture of despair, and it is hard not to feel it. The metaphor of the darkest hour becomes real for me in those first days after the second operation, both eyes recovering, a time when faces are blurry and indistinct. I am acutely aware of time as a palpable dimension, made to pass by music and books on tape. My vision slowly improves, leaving me able to do my job, and determined never to complain about having to do it, never to whine about returning in the middle of the night to the ICU, never to complain about a presentation or journal club. And every morning I am both grateful to be able to see and afraid it might not last. I am like my patients, like all survivors of illness, left with gratitude and uncertainty, wonder and fear.

A Piece of My Mind Section Editor: Roxanne K. Young, Associate Senior Editor.

Friday, August 13, 2010

Some Inspirational Art

I was about to fold my tent this evening after a long day of writing, however as I was finishing my evening rounds on blog lines, my favorite RSS aggregator, I came upon this….

I need to share what I consider an outstanding post by Regina Holliday and here almost biblical art work that reminds me of the last supper, Moses receiving the ten commandments. the parting of the red sea, and the last supper.

image

 

SHARE THIS WITH ME,  and thank you Regina….what a wonderful way to turn off the day.

GML

Thursday, August 12, 2010

The Meaningful Use May Mean

This morning I had a chance to sit in on a conference hosted by Centricity, to discuss meaningful use as a criteria for selecting your next EMR or upgrading your present EMR.

Both physician providers represent fairly large user groups who already have implemented GE Centricity, an enterprise sized EMR solution.

The complete slide deck of the presentation will be available in the next several days.

Several of the presenters are physicians  MDs.  Med Star Health is a present  user of their EMR solution.  Peter Basch M.D., an internist and member of this large group  reviewed the tenets of HITECH and its financial incentives for adopters, and penalties for non adopters.  Groups in underserved areas will receive an additional 10% incentives.  Additional funding will also come from Medi-caid, up to $60,000 per provider.

Dr Basch presents an excellent review of the M.U. development process. It seemed quite credible.

Meaningful use should be easily obtainable by present users.  New users will find these criteria are reachable..

Stage 1: final rule metrics have been announced:

Latest edition provides:

Fewer, Lower Thresholds, and  reduced reported burden.

Changes have been made to allow slower adoption and still obtain incentives.

Peter Basch M.D. presented their Med Star  MU Roadmap

His pronouncements are clear and loud.

image

click on the image, and then use ctrl + or ctrl – to zoom in and out.

Meaningful use is a done deal, the law of the land. First step in how hospitals and providers will function and be reimbursed in the future. 

Non-Medicare providers will find that other insurers are already adopting MU as criteria. and cannot be ignored.

A vital take-away is that you MUST be analytic and pre-qualify your intended EMR to be MU compatible and CERTIFIED. This is so important that empty promises from vendors  are meaningless.  (show me the beef!!)

Simeon Schwartz MD of Med West pointed out the one button coding click in their EMR from doctor to carrier, with no other human hand intervening. This generates efficiency and immediate ROI.

eRx adds major efficiency to ordering prescriptions and also in future ACO verification of patient receiving and using the medications prescribed.

My takeaway is:

BE IN A LARGE GROUP, JOIN A GROUP, INTEGRATE YOUR PRACTICE WITH ANOTHER PRACTICE.

IF YOU ARE SOLO……GOOD LUCK !!! START NOW, HIRE A CONSULTANT TO DO THE HEAVY LIFTING, DO NOT BUY CHEAP, THIS IS ONLY GOING TO BECOME MORE BURDENSOME UNLESS THE SYSTEM YOU ACQUIRE IS ROBUST AND CAN DO THE MU THING….

This is the beginning of meaningful use, not the end. Do not implement minimalistic solutions.

Wednesday, August 11, 2010

Social Networking Update

 

It’s time for Health Train Express  to do some CME in social networking and all the new words, and eponyms that develop with a new subspecialty in medicine.

How does social networking impact on medicine and your practice?  Well, it is a huge new aspect which all providers need to watch closely.

It is no longer a ‘geek thing”  or just  a place where Betty Boop posts some nudie pictures that predatory “perps” lurk and wait. 

There is or should be no ‘prejudice’ or strange looks from our colleagues at those of us who know about and use ‘social media’ in the course of our day.

It has become a new highway of information, rivaling Google and perhaps surpassing it’s formidable market presence.  In fact I would bet your bottom dollar that Google, Apple, Yahoo and others are watching closely, and perhaps even leasing out their excess capacity on their network servers to facebook, linkedin and others.  I even predict a buyout in the near future of one of these networking services by another network site. 

There are several books and web sites dedicated to learning the basic lingo of social networking.  Read one or some of these ‘esteemed’ reference sources….

Board Certification in one or all of these areas will soon be available.(tongue in cheek)

That's why, with help from the smart folks at technology publisher O'Reilly Media, they’ve assembled a glossary of social-networking terms every physician should know. And for all the techno-jargon that gets tossed around, rest assured you don't have to be a member of the Geek Squad to fathom the implications these issues have for strategy and budgeting

I recommend the following publications:

Facebook, The Missing Manual

Book cover of Facebook: The Missing Manual

YouTube: An Insider's Guide to Climbing the Charts

 

 

With 3.2 million unique visitors each month, LinkedIn is by no means the largest social network around. However, thanks to its unique niche, LinkedIn might be the most valuable network you can join as a business professional.

A list of Social Networking Sites

And finally last, but not least (as 0f June 2009) the list of medical and health related social networking sites.

Meaningful Use or Meaningless Data

 image

The climb (path) to Meaningful Use

 

Today  MARGALIT GUR-AIRE waxed mightily in his writing on the Health Care Blog.  I like MARGALIT GUR-AIRE , a brilliant medical writer, who far exceeds my minimalistic attempts to display my inadequacies in the written word.

 

Meaningful or meaningless data?  It remains to be seen about the benefits of all this data. First of all the 'system' is currently 'non existent" except for relatively small silo's of information limited to established larger health institutions and/or medical clinics  that have integrated EHRs
Much of the stimulus funding for EMR by HITECH has been driven by empty promises for the potential of a unified data sharing system. The system as envisioned and yet to be implemented mandate of APPA will not even begin to grow until after 2014.  Larger portions of the country are not served by the broadband connections required to become a part of NHIN or even local HIEs.


And there will be a significant segment of providers who simply will not participate even with the incentives which are inadequate.
The larger question is who will even look at this data as it accumulates in storage media hidden away in systems deep underground in government systems that are already obsolete?? So not to discount all the experts in this era, while it all has great potential, there remains many visible pitfalls, and unknown barriers to the utopia of EMR. There is not much in it for the individual provider in terms of face to face patient contact other than medications, Rx Writing, and history and physical findings. And these metrics are difficult to obtain during a patient encounter, creating diminished efficiency whose cost will be transferred to fewer patient encounters, less time to talk to patients, and more, not less frustration for the provider.  We all would like to drive that BMW, but few can afford it, and many sell it when the warrantee ends.
But what do I know....I usually am correct and see ten or more years into the future, having experienced 40 years of medical practice.  My younger brethren have yet to experience the upheavals caused by well intended tsunamis that travelled through medical reimbursement changes in the past. But that will not matter in a health system that will largely become a civil service department of the government(s).

The Computer is  a  Moron (Peter Drucker, 1909-2005 elaborates further.

Tuesday, August 10, 2010

Another Cool Thing

I love time savers. As a physician, like all of you I am pressed for time. Anything that shortens my tasks without sacrificing quality is a ‘meaningful use” nominee.

Having said that I have just discovered the utility of ‘tiny url’. This little doo-hickey is a downloadable add in for either Firefox (my preferred browser) and Internet Explorer. With one tiny click on your toolbar, a copy and a paste you are off and running. I see great potential for it’s use in EMR applications.

Another tiny tidbit for today.  Their domain name is in the Cocos Islands. (is this another offshore financial opportunity?) (Australian territory)

Sunday, August 8, 2010

Another CMS Eponym

What is a “ ZPIC”  ?  (see below)

 

 

WASHINGTON (AP) - They don't seem that interested in hot pursuit. It took private sleuths hired by Medicare an average of six months last year to refer fraud cases to law enforcement.

Have you looked in your post office lately? Perhaps your photo will be up there, soon.

 

According to congressional investigators, the exact average was 178 days. By that time, many cases go cold, making it difficult to catch perpetrators, much less recover money for taxpayers.

A recent inspector general report also raised questions about the contractors, who play an important role in Medicare's overall effort to combat fraud.

click on the image

Groucho, Harpo and Zeppo.  Question of the day, Who were the other two Marx brothers????

 

graphic

 

Out of $835 million in questionable Medicare payments identified by private contractors in 2007, the government was only able to recover some $55 million, or about 7 percent, the report found.

Medicare overpayments - they can be anything from a billing error to a flagrant scam - totaled more than $36 billion in 2009, according to the Obama administration.

 

As ranking Republican on the Senate panel that oversees Medicare, Grassley is trying to find out why it takes the contractors so long, and how much the government is currently paying the companies. In 2005, taxpayers paid them $102 million.

At least seven private companies Medicare calls "Program Safeguard Contractors" are working to detect fraud, part of a program that dates to the late 1990s. They oversee specific areas of jurisdiction, and some have more than one contract with Medicare.

 

In practice, their performance has been uneven. The contractors have widely different track records. One identified $266 million in overpayments in 2007, while another found just $2.5 million, the Health and Human Services inspector general said in May.

 

The private sleuths will now be called "Zone Program Integrity Contractors" - or ZPICs for short.

Saturday, August 7, 2010

We’re Back !!!

 

As I promised the technical glitches have been fixed.

I reposted several previous posts to be sure it is working.

Have a nice weekend….

 

thank you Microsoft

The Clothesline

I don't know about you, but I and most physicians are fed up with being hung out to 'dry'.

Same old, same old.

Doctors with Medicare patients will start seeing a 21 percent pay cut this week after Congress failed to defer the cuts by two more years.

This Story appears today in the Washington Post.

  • The Senate had until June 1 to avert the cuts. It is not expected to vote by Tuesday, when the Center for Medicare and Medicaid Services' temporary hold on Medicare claims expires.

Some members of the American Medical Association signed white lab coats instead of a petition to voice their displeasure on Sunday at the group's annual meetings in Chicago. The coats will be delivered to lawmakers in Washington on Friday, a spokeswoman said.

"The Senate's failure to act before June 1 made the 21 percent cut the law of the land," AMA President J. James Rohack said in a statement. "Physicians will start seeing a 21 percent cut in Medicare payments this week that will hurt seniors' health care as physicians are forced to make practice changes to keep their practice doors open."

Legislation to restore doctor's pay -- known as the "doc fix" -- is part of a broader aid package that includes jobless benefits and more financial aid for the states. In his Saturday radio address, President Obama called on lawmakers to avert the pay cuts, faulting Republicans for the delay. "After years of voting to defer these cuts, the other party is now willing to walk away from the needs of our doctors and our seniors," Obama said.

Republicans call the package fiscally irresponsible and said it would add $80 billion to a bloated federal deficit. Some moderate Republicans say they will vote for the package if the cost is offset by cuts elsewhere in the federal budget.

President Obama this weekend told us all how much he 'cares' about doctor reimbursement. 

 

What a sham.   image

 

If that were the case there should have been room in the monstrous 1200 page heath reform bill to (link takes a while to load))include a permanent fix to the SGR (sustainable growth rate)

Better pony up and get some more clothespins....before they are all gone!!

Vending Machine Medicine

I was reading Distractible MD this morning and came across this photo that Rob Lambert posted.

image I could not resist passing this along to my readers.  It says a lot about what has and is happening to our domain as physicians.  I wonder if it talks too.

The Yo-Yo Effect

image

The past several months reveal how disconnected the plan for health care reform has evolved. There was little transparency regarding the evolution of the bill, except for political posturing. The present administration has no experience in business leadership, nor basic economic theory.

The fact that the flawed SGR formula, hastily conceived in the early 1990s, was not addressed in the health reform bill attests to the simple fact that cost is a major factor in the legislation. Universal care was never a top priority except to assuage the proletariat.  SGR was and is held out as a bargaining chip and as a diversion for most  physicians.

The effects of the SGR impact very severely on ophthalmologists, urologists, geriatricians, some internists  and somewhat on cardiologists and pulmonologists.  These practices serve a large medicare population, and the SGR impact as presently structured or not eliminated will be devastating.

Primary care physicians can select to minimize medicare or eliminate it all together from their business model, with much less impact on their practices.

Thus, some specialists will have little choice but to either quit entirely, or fire half their staff, and reduce the quality and accessiblity of their practices to senior citizens.  These practices will ill afford to acquire new technology.  The physical structures of medicine will decline, poor maintenance, bare floors, and peeling paint.

The past several months have been  a Yo yo  for physicians  with hope for resolution of the SGR fiasco, and then dashed as we are used as a political football.

image

Friday, August 6, 2010

Non Publishing Notice

I have just discovered my daily blog has not published for the past week.  I am working on finding the cause and solution.. I will be back!!!