Showing posts with label health train express. Show all posts
Showing posts with label health train express. Show all posts

Friday, May 30, 2014

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.





Thursday, May 15, 2014

HTE DIGEST Vol 1 No 2

HTE Health Train Express is Celebrating 10 years of publishing on the internet. Throughout this month we will publish articles from the past ten years.


A substantial number of Medicare Beneficiaries receive low value medical care. Several criteria were used to measure low value care. Medicare spent $8.5 billion, or $310 per beneficiary, on services detected by the study's more sensitive measures of low-value care, while spending on low-value services with more specific definitions totaled $1.9 billion, or $71 per beneficiary.
That accounted for 0.6 percent to 2.7 percent of overall spending, depending on the measures' level of sensitivity. While representing "modest proportions" of total Medicare spending, the researchers note the findings suggest widespread overuse of unnecessary treatments. JAMA Study  KHN Study

Virginia is first state to release rate proposals for 2015. Premium rates will rise 3.3% (KFHP), 8.5% (Wellpoint Anthem). to accomodate poorer health of many new members likely to boost their health care utilization.

Webinar events  Mark Your Calendars:  A collection of free webinars of timely subjects

> Next-Generation Subrogation Solutions - Wednesday, June 4, 2014, 12pmET / 11amCT / 9amPT
> Healthcare's new entrants: Who will be healthcare's Amazon.com? - Wednesday, June 3rd, 11am ET / 8am PT
> New Rx Savings Strategies for Payers - SPONSORED BY: Elsevier
> The Growing Challenge of Medical Identity Theft - Thursday, June 5, 2014 | 1pm ET, 11am PT
> The Internet of Things: How connected devices put data in your hands - Thursday, June 12th, 1pm ET / 10am PT
> Developing for the Internet of Things: Challenges and Opportunities - Wednesday, June 18th, 2pm ET
> Boosting physician adoption of CPOE to maximize its benefits - Wednesday, June 25th, 2pm ET/ 11am PT


Insurers issued about $513 million in rebates for 2012 under the medical-loss ratio requirement, according to a Commonwealth Fund report released Tuesday. That's half of the amount paid in 2011, showing greater compliance by insurers with the Affordable Care Act's MLR rule.  Commonwealth Fund announcement and study (.pdf)


Health IT News:
> Within two decades, Google might dominate the medical technology industry as the company currently spends $8 billion a year on research. Article

During the past ten years  adoption of EHR, HDX, and Hospital EHRs created a tsunami of demand for experienced IT professionals.  Despite funding for training of HIT personel via the HITECH ACT ongoing demand has created a shortage, impacting EHR installations, and Health Care Reform.  Much of Health Care Reform requires integration of data silos and data analytics

Controversy and disagreement continues in regard to Federal mandates for inclusion of Meaningful use standards for electronic health records. Meaningful use was designed to guide transition to EHRs that would exchange data, increase patient involvement, and allow data collection for analysis.  Providers are mandated to either modify their present EHR or completely replace their software.  This comes at a time when there are many competing increases in bureaucracy, planned adoption of the ICD-10 diagnosis tables.  Providers have said that the definition of Meaningful Use by HHS is not the same as meaningful use by providers.  EHRs continue to be inconsistent, not user friendly, nor intuitive.