Physicians Have Abdicated Power

Background:

During the last two decades physicians have abdicated their role to CMS and payers fo policing each other. Resident physicians are closely supervised and gradually given more responsibility for decision making as they proceed from PGY 1-PGY4.  As a chief resident they are responsible for much of the activity of junior residents. Surgical and/or medical residents in certain specialties have their proposed surgical cases reviewed by either a chief resident, or director of the training program prior to scheduling.

During the first year of practice or if the MD change hospitals medical staff regulatons require providers to have a  proctor during a certain number of cases to insure proper judgment and  competence.

Following this period they are allowed to operate alone.  Further proctoring is usually not necessary unless there is a complication or a death. Usually this takes place in a departmental meeting for review. This often serves as a learning experience and is not a punitive affair. If the difficulties persist the physician will be required to obtain further training or more supervision until he demonstrates competence.  The entire process is physician led. It is private and confidential and not discoverable by non-physicians.

During the last two decades physicians have been lax in many regards, and have not required chart reviews prior to surgery nor review of treatment protocols unless there is an untoward event resulting in a morbidity or mortality and after the fact.

Current:

The review and authorization procedure now is conducted by insurers for prior authorization by a non-physician or a medical director for a payer.  This occurs away from the clinical setting when the physician submits the case  history, and proposed procedure.  The intensity of the review by CMS and payers is usually determined by the level of cost and number of procedures that are done.  The ultimate goal is not patient safety, nor quality of care. It is to reduce cost.  Their benchmark for what is reviewed is a simple algorithm.   #of cases X cost/case = total cost. Cases that are done in high volume, or high expense will require prior authorization. Such cases or diagnostics include Cataract removal, Hysterectomy, Spine surgery, Interventional cardiology. Many of these are surgical or advanced medical interventions. Many of the reviews are for expensive imaging, such as MRI or CT imaging.

There has been a gradual erosion of self determination and  pre-surgical review by physicians and surgeons, allowing CMS and payers to intrude into physician-patient relationshiphs.

Future:

Physicians will reclaim the role of ascertaining quality control and prevention of abuse and fraud by peer-review of  expensive and high volume procedures prior to procedures, both diagnostic and Invasive.  It will be required that all pre-surgical cases be reviewed by another member of the department prior to scheduling (except for emergent or urgent need.) The insurance company should not have any role in  prior authorization.  That will be the purview of medical staff, much like PQRI was performed in the late 1980s for cataract removal.  

This system will allow peer and case review for the medical staff and immediate feedback for non-compliant providers.

The insurance system will be simplified.   Delays and/or denials could be eliminated for review, authorization and payments.  Administrative expense could be reduced. This will require some additonal time and effort by physicians.  That is the price for professional freedoms.  Freedom takes effort to maintain.

Is this an idealized vision for the future, or will it come to pass?  Only you and I can decide.

The time has come to draw a red line in the sands of health care.

The 3 I s

The Three “I’s” of the Affordable Care Act

The triple ‘AIM’ is a term often quoted by health policy pundits.

CALIFORNIA’S MEDICAID CONUNDRUM

While California’s Medicaid enrollment exceeded projections by 1.4 million, many of those new enrollees had already been eligible for the program. The federal government provides states a 100% Medicaid match through 2016, but that’s only for those individuals newly eligible under the 2010 health-care law; if individuals who had already been eligible for but not enrolled in Medicaid come out of the woodwork, states will pay a portion of those costs. In 2012, the Department of Health and Human Services estimated that states would pay an average of 43% of those enrollees’ Medicaid costs in this fiscal year.

Some states opted to expand Medicaid under the health-care law, raising costs and budgetary pressures at a time of volatile tax revenue. In some cases, the result has been cognitive dissonance. California Gov. Jerry Brown was quoted in Thursday’s Journal saying: “We can’t spend at the peak of the revenue cycle--we need to save that money, as much of it as we can.” But two days earlier, Mr. Brown had expressed pride in the “huge social commitment” that health-care expansion represented in his state--even as it caused a billion-dollar overspend.

Ultimately, states that expand Medicaid could face pressure to cut other important services, whether health-related or in areas such as corrections or education. Recent trends have moved toward reductions because when an irresistible force such as a shrinking tax base meets an immovable object--the rising costs from expanding Medicaid--something has to give.

SOURCE: Wall Street Journal

The three Is of the Affordable Care Act,  Inadequate  Ill-conceived,   and incompetent

Physicians have Abdicated Power

Background:

During the last two decades physicians have abdicated their role to CMS and payers fo policing each other. Resident physicians are closely supervised and gradually given more responsibility for decision making as they proceed from PGY 1-PGY4.  As a chief resident they are responsible for much of the activity of junior residents. Surgical and/or medical residents in certain specialties have their proposed surgical cases reviewed by either a chief resident, or director of the training program prior to scheduling.

During the first year of practice or if the MD change hospitals medical staff regulatons require providers to have a  proctor during a certain number of cases to insure proper judgment and  competence.

Following this period they are allowed to operate alone.  Further proctoring is usually not necessary unless there is a complication or a death. Usually this takes place in a departmental meeting for review. This often serves as a learning experience and is not a punitive affair. If the difficulties persist the physician will be required to obtain further training or more supervision until he demonstrates competence.  The entire process is physician led. It is private and confidential and not discoverable by non-physicians.

During the last two decades physicians have been lax in many regards, and have not required chart reviews prior to surgery nor review of treatment protocols unless there is an untoward event resulting in a morbidity or mortality and after the fact.

Current:

The review and authorization procedure now is conducted by insurers for prior authorization by a non-physician or a medical director for a payer.  This occurs away from the clinical setting when the physician submits the case  history, and proposed procedure.  The intensity of the review by CMS and payers is usually determined by the level of cost and number of procedures that are done.  The ultimate goal is not patient safety, nor quality of care. It is to reduce cost.  Their benchmark for what is reviewed is a simple algorithm.   #of cases X cost/case = total cost. Cases that are done in high volume, or high expense will require prior authorization. Such cases or diagnostics include Cataract removal, Hysterectomy, Spine surgery, Interventional cardiology. Many of these are surgical or advanced medical interventions. Many of the reviews are for expensive imaging, such as MRI or CT imaging.

There has been a gradual erosion of self determination and  pre-surgical review by physicians and surgeons, allowing CMS and payers to intrude into physician-patient relationshiphs.

Future:

Physicians will reclaim the role of ascertaining quality control and prevention of abuse and fraud by peer-review of  expensive and high volume procedures prior to procedures, both diagnostic and Invasive.  It will be required that all pre-surgical cases be reviewed by another member of the department prior to scheduling (except for emergent or urgent need.) The insurance company should not have any role in  prior authorization.  That will be the purview of medical staff, much like PQRI was performed in the late 1980s for cataract removal.  

This system will allow peer and case review for the medical staff and immediate feedback for non-compliant providers.

The insurance system will be simplified.   Delays and/or denials could be eliminated for review, authorization and payments.  Administrative expense could be reduced. This will require some additonal time and effort by physicians.  That is the price for professional freedoms.  Freedom takes effort to maintain.

Is this an idealized vision for the future, or will it come to pass?  Only you and I can decide.

The time has come to draw a red line in the sands of health care.

Big Data, Friend or Foe ?

No Child Left Behind

Recently I heard an NPR report on the increasing displeasure about The “No Child Left Behind”, a Department of Education program initiated during the Bush administration.  It’s stated goal was to improve the performance of children in school.  Teachers were to be held accountable for their student’s performance as measured by the ‘Star Test’.  Many teachers became disillusioned wiith teaching using this metric as a measure of their competence. Many suffered “burn out’ and left the profession.  The mantra “teaching to the test’ became a war cry for the movement.  Charter schools popped up throughout the nation as a safety valve for the embattled eudcational system to remove teachers from the bureaucracy which now became more important than understanding the subject matter. Teachers were to improve test scores to a benchmark to demonstrate success in revised curricula.  Data about improvement in the weak portions of the school system became paramount, rather than keynoting the best parts of the American School System.

Big Data, Friend or Foe ?

Does this sound similar to our current health care conundrum? HHS, another federal bureaucracy, and many state health departments are intent on the same measurements collecting ‘big data’ from elaborate  HIT structure incentivized with federal tax dollars.  The similarity is frightening as the powers that be are more interested in figures than real patient care.  Bureaucrats are not seeking improved health care, just the measure of how much  can be saved with shorter stays in hospital. In order to accomodate these mandates, massive consolidation is taking place in health organizations.

Obamacare and Narrow Network Exclusions

Some insurers' narrow networks include a mismatch among providers where in-network doctors don't have privileges at any of the in-network hospitals.

This has become more apparent as patients and providers line up with the nitty-gritty real-time effort to provide care and specialty referrals.  Narrow networks without adequate regional coverage for specialists and hospitals do not become evident until the time when it is needed. The consequence of this is delayed treatment and decreased quality of care.

Although there are private insurers participating in the Affordable Care Act, the provider lists for the ACA are not the same as regular insurance policies. And there is often a mismatch or an absence of an urgent care center in a narrow network, causing a patient to have to go to an emergency department. This has the paradoxical effect of a very expensive ED visit, for which the patient is further penalized with a high co-pay.  Doctors aren't the only providers complaining about the mismatches--hospitals also want a solution to narrow network problems caused by health plans failing to sort through the physician admitting relationships, the article noted.

Such discrepancies may lead to tougher restrictions for insurer networks. The Centers for Medicare & Medicaid Services already proposed a policy requiring payers to expand their networks to include essential community providers or risk being kicked out of the marketplaces

Related Articles:

Insurers must break consumers of choice habit

State-by-state look at narrow networks

Enable consumer choice when offering narrow networks

Expensive plans don't mean large provider networks

How to form high-quality narrow networks

CMS aims to broaden exchange provider networks

Medicaid Premature Birth

Medicaid is much like a premature child….not ready for discharge, and underweight.

Webinar:  Online

Details AEI, Twelfth Floor 1150 Seventeenth Street, NW Washington, DC 20036 Participants Introduction: Arthur C. Brooks, AEI Remarks: Mike Pence, Governor of Indiana Register RSVP to attend this event. To watch live online, click here on Monday, May 19 at 11:00 AM ET. Registration is not required. Contacts For more information, please contact Emily Rapp at emily.rapp@aei.org, 202.862.5212. For media inquiries, please contact MediaServices@aei.org, 202.862.5829. American Enterprise Institute for Public Policy Research | 1150 17th Street, N.W., Washington, D.C. 20036 P: 202.862.5800 | F: 202.862.7177 | www.aei.org Get the new, free AEI Essentials mobile app for Apple, Android, or Kindle devices. Demo video | Downloading instructions Follow AEI and AEI Scholars on:

The operation of Medicaid varies greatly from state to state. Funding for medicaid is shared between the state and the federal treasury.  It is complicated, and from there on down it becomes worse…..eventually serving as a ‘safety-net’ for the medically indigent and financially unfortunate.

Medicaid attempts to fill a very large black hole,  and as such gravity will spin and suck it into it’s voracious maul.

Many states are reappraising how medicaid functions in their state.  The feds set a standard and in order for states to receive their matching funds from the U.S. Treasury states must comply...Who cares about the beneficiaries of our collective largesse.  Medicaid services often consume most of state budgets, and it is the focus of looking for fraud and abuse, or waste.  Waste by whom ?  Patients, providers, or perhaps the very medicaid system. The medicaid system produces a  prodigious amount of data, first stored on paper and now on a storage drive in some cloud server facility.  The paperwork at times gets lost, deadlines for filing are often less than one week after the request is received.

It deserves reevaluation for the sake of the increasing number of beneficiaries who are eligible for Medicaid due to the Affordable Care Act.

Some states are creating out of the box solutions including market driven private models.

Market-based Medicaid reform in the age of Obamacare:

Remarks from Indiana Gov. Mike Pence

Indiana has been at the forefront for innovations,including the earliest health data exchange. Perhaps things get done in Indiana because it is in the center of the country, it is not overpopulated, and is also in the political center and moderate.

Since taking office in January 2013, Indiana Governor Mike Pence has stressed the need for state-level innovation to address pressing national issues. In the area of Medicaid, Gov. Pence has promoted the Healthy Indiana Plan (HIP), which has operated on a demonstration basis in Indiana for several years and uses a consumer-driven model featuring health savings accounts (HSAs).

After negotiating a one-year waiver for 40,000 HIP recipients, Gov. Pence has now developed plans to expand the program as an alternative to Medicaid. Please join us for a conversation with Gov. Pence as he discusses how he plans to use private market–based reforms, employer-based plans, and HSAs to transform health care in a fiscally responsible manner for the Medicaid-eligible population in Indiana.

What are your suggestions ?

Sebelius out, Burwell In

SPOTLIGHT ON... Senate panel approves Mathews Burwell as next HHS secretary

A Senate panel on Wednesday approved President Barack Obama's recommendation of Sylvia Mathews Burwell for the next secretary of U.S. Department of Health and Human Services, reports the Los Angeles Times. While three Republicans voted against Mahews Burwell, eight gave the OK along with all 13 Democrats on the Senate Finance Committee. Burwell worked in the Clinton White House, was part of the Bill & Melinda Gates Foundation and heads the Office of Management and Budget.

Burwell’s confirmation follows 4 years after the Affordable Care Act which charged her with implementing the mandates given her by the  U.S. Congress. Other than President Obama’s highly visible multi-media campaign Kathleen Sebelius was prominent during the run-up to enrollment opening. Following that fiasco, her credibility evaporated.  Burwell faces a relatively quiet period as the initial post enrollment period progresses.  Burwell’s most recent public office was in the OMB. She has no direct background in health care administration.

CMS to Let Docs Use Older EHRs in Incentive Program

For those physicians who purchased a new EHR prior to the later stages of MU mandates there is a sign of some relief as CMS has waived the requirement in some cases.

CMS offers flexibility in EHR program, but little time to flex

For the second time this year, the government was forced to punt on a major health IT initiative, potentially adding another year before early adopters of EHRs must meet more stringent requirements. (MODERN HEALTHCARE)

FULL STORY »

CMS and ONC Release NPRM Allowing CEHRT Flexibility and Extending Stage 2

Today, CMS and ONC released a notice of proposed rulemaking (NPRM) that would allow providers participating in the EHR Incentive Programs to use the 2011 Edition of certified electronic health record technology (CEHRT) for calendar and fiscal year 2014.

Read More >>

ITIF: States must embrace telehealth, or else

The Information Technology & Innovation Foundation is calling on Congress to adopt a national telehealth policy - and penalize states who don't fall in line.

Study: Docs need to promote mHealth apps

The current model for mHealth apps is a commercially driven approach B2C rather than a provider to consumer driven model.  Patients are currently at the mercy of marketing and have little knowledge of what a reliable or credible device or software app is. Physicians must learn about these apps, and their functionality, and prescribe devices as DME to ensure compliance.  Eventually this will become standard of care.  FDA guidance is strongly needed or outright regulation as a medical device to ensure accuracy.  Many are WiFi enabled and will require HIPAA compliance for data transferee via the internet. WiFi is notoriously open to hacking and encryption is a mandatory component.  This is especially important for remote monitoring

---

Time for Government to Step Out of the Way of EHR and Let the Market Takeover? Posted: 22 May 2014 01:30 PM PDT The always interesting and insightful John Moore from Chilmark research has a post up that asks a very good question. The question is whether it’s time for the government to get out of the EHR regulation business and let the … Continue reading→

mHealth and Where It’s Heading with Alan Portela Posted: 22 May 2014 07:37 AM PDT I was excited to sit down with Alan Portela, CEO of AirStrip, in our latest installment of Google Plus Hangouts with top healthcare IT leaders. Along with telling a little bit about the AirStrip story, we talk a lot about … Continue reading →

Physician Abdication of Power

Background:

During the last two decades physicians have abdicated their role to CMS and payers fo policing each other. Resident physicians are closely supervised and gradually given more responsibility for decision making as they proceed from PGY 1-PGY4.  As a chief resident they are responsible for much of the activity of junior residents. Surgical and/or medical residents in certain specialties have their proposed surgical cases reviewed by either a chief resident, or director of the training program prior to scheduling.

During the first year of practice or if the MD change hospitals medical staff regulatons require providers to have a  proctor during a certain number of cases to insure proper judgment and  competence.

Following this period they are allowed to operate alone.  Further proctoring is usually not necessary unless there is a complication or a death. Usually this takes place in a departmental meeting for review. This often serves as a learning experience and is not a punitive affair. If the difficulties persist the physician will be required to obtain further training or more supervision until he demonstrates competence.  The entire process is physician led. It is private and confidential and not discoverable by non-physicians.

During the last two decades physicians have been lax in many regards, and have not required chart reviews prior to surgery nor review of treatment protocols unless there is an untoward event resulting in a morbidity or mortality and after the fact.

Current:

The review and authorization procedure now is conducted by insurers for prior authorization by a non-physician or a medical director for a payer.  This occurs away from the clinical setting when the physician submits the case  history, and proposed procedure.  The intensity of the review by CMS and payers is usually determined by the level of cost and number of procedures that are done.  The ultimate goal is not patient safety, nor quality of care. It is to reduce cost.  Their benchmark for what is reviewed is a simple algorithm.   #of cases X cost/case = total cost. Cases that are done in high volume, or high expense will require prior authorization. Such cases or diagnostics include Cataract removal, Hysterectomy, Spine surgery, Interventional cardiology. Many of these are surgical or advanced medical interventions. Many of the reviews are for expensive imaging, such as MRI or CT imaging.

There has been a gradual erosion of self determination and  pre-surgical review by physicians and surgeons, allowing CMS and payers to intrude into physician-patient relationshiphs.

Future:

Physicians will reclaim the role of ascertaining quality control and prevention of abuse and fraud by peer-review of  expensive and high volume procedures prior to procedures, both diagnostic and Invasive.  It will be required that all pre-surgical cases be reviewed by another member of the department prior to scheduling (except for emergent or urgent need.) The insurance company should not have any role in  prior authorization.  That will be the purview of medical staff, much like PQRI was performed in the late 1980s for cataract removal.  

This system will allow peer and case review for the medical staff and immediate feedback for non-compliant providers.

The insurance system will be simplified.   Delays and/or denials could be eliminated for review, authorization and payments.  Administrative expense could be reduced. This will require some additonal time and effort by physicians.  That is the price for professional freedoms.  Freedom takes effort to maintain.

Is this an idealized vision for the future, or will it come to pass?  Only you and I can decide.

The time has come to draw a red line in the sands of health care.

ACA and the Three I s

The Three “I’s” of the Affordable Care Act

The triple ‘AIM’ is a term often quoted by health policy pundits.

CALIFORNIA’S MEDICAID CONUNDRUM

While California’s Medicaid enrollment exceeded projections by 1.4 million, many of those new enrollees had already been eligible for the program. The federal government provides states a 100% Medicaid match through 2016, but that’s only for those individuals newly eligible under the 2010 health-care law; if individuals who had already been eligible for but not enrolled in Medicaid come out of the woodwork, states will pay a portion of those costs. In 2012, the Department of Health and Human Services estimated that states would pay an average of 43% of those enrollees’ Medicaid costs in this fiscal year.

Some states opted to expand Medicaid under the health-care law, raising costs and budgetary pressures at a time of volatile tax revenue. In some cases, the result has been cognitive dissonance. California Gov. Jerry Brown was quoted in Thursday’s Journal saying: “We can’t spend at the peak of the revenue cycle--we need to save that money, as much of it as we can.” But two days earlier, Mr. Brown had expressed pride in the “huge social commitment” that health-care expansion represented in his state--even as it caused a billion-dollar overspend.

Ultimately, states that expand Medicaid could face pressure to cut other important services, whether health-related or in areas such as corrections or education. Recent trends have moved toward reductions because when an irresistible force such as a shrinking tax base meets an immovable object--the rising costs from expanding Medicaid--something has to give.

SOURCE: Wall Street Journal

The three Is of the Affordable Care Act,  Inadequate  Ill-conceived,   and incompetent

The Three Is of the ACA

The Three “I’s” of the Affordable Care Act

The triple ‘AIM’ is a term often quoted by health policy pundits.

CALIFORNIA’S MEDICAID CONUNDRUM

While California’s Medicaid enrollment exceeded projections by 1.4 million, many of those new enrollees had already been eligible for the program. The federal government provides states a 100% Medicaid match through 2016, but that’s only for those individuals newly eligible under the 2010 health-care law; if individuals who had already been eligible for but not enrolled in Medicaid come out of the woodwork, states will pay a portion of those costs. In 2012, the Department of Health and Human Services estimated that states would pay an average of 43% of those enrollees’ Medicaid costs in this fiscal year.

Some states opted to expand Medicaid under the health-care law, raising costs and budgetary pressures at a time of volatile tax revenue. In some cases, the result has been cognitive dissonance. California Gov. Jerry Brown was quoted in Thursday’s Journal saying: “We can’t spend at the peak of the revenue cycle--we need to save that money, as much of it as we can.” But two days earlier, Mr. Brown had expressed pride in the “huge social commitment” that health-care expansion represented in his state--even as it caused a billion-dollar overspend.

Ultimately, states that expand Medicaid could face pressure to cut other important services, whether health-related or in areas such as corrections or education. Recent trends have moved toward reductions because when an irresistible force such as a shrinking tax base meets an immovable object--the rising costs from expanding Medicaid--something has to give.

SOURCE: Wall Street Journal

The three Is of the Affordable Care Act,  Inadequate  Ill-conceived,   and incompetent

Dr. Wes: It's Not About the Physician

Dr. Wes: It's Not About the Physician

Health Care Development Challenges have developed into a ‘crowdsourcing tool for health foundations. The rewards are substantial, and come at a time when developers are searching for funding.  Make your choice. More Challenges, More Prizes! We launched three more challenges this week. Apply Now! Pilot Health Tech NYC Deadline May 23, 2014 Total Prizes: $1,000,000 California Health Care Foundation Design Challenge Deadline: June 27, 2014 Total Prizes: $10,000   NYS Health Innovation Challenge Deadline: July 24, 2014 Total Prizes: $43,000   PCORI Matchmaking App Deadline: August 15, 2014 Total Prizes: $150,000 Palo Alto Medical Foundation Challenge Official Launch: June 11, 2014 RWJF Plan Choice Challenge Official Launch: Coming Soon